Narrow Results Clear All
- WebM&M Cases 87
Perspectives on Safety
- Perspective 15
- Commentary 659
- Review 334
- Study 2036
- Image/Poster 10
- Slideset 4
- Book/Report 135
- Legislation/Regulation 44
- Newspaper/Magazine Article 179
- Newsletter/Journal 6
- Special or Theme Issue 54
- Toolkit 25
- Web Resource 155
- Award 7
- Clinical Guideline 4
- Grant 6
- Meeting/Conference 26
- Press Release/Announcement 18
Communication between Providers
- Sbar 17
- Communication between Providers 549
Culture of Safety
- Just Culture 14
Education and Training
- Simulators 107
- Students 51
Error Reporting and Analysis
- Error Analysis 546
- Error Reporting 425
Human Factors Engineering
- Checklists 173
Legal and Policy Approaches
- Regulation 42
- Logistical Approaches 222
- Policies and Operations 6
Quality Improvement Strategies
- Benchmarking 74
- Reminders 20
- Research Directions 22
- Specialization of Care 209
- Teamwork 292
- Clinical Information Systems 364
- Computer-Assisted Therapy 7
- Telemedicine 10
- Transparency and Accountability 5
- Alert fatigue 16
- Device-related Complications 172
- Diagnostic Errors 211
- Discontinuities, Gaps, and Hand-Off Problems 419
- Drug shortages 8
- Failure to rescue 5
- Fatigue and Sleep Deprivation 74
- Identification Errors 108
- Inpatient suicide 2
- Interruptions and distractions 73
- Delirium 6
- Medication Errors/Preventable Adverse Drug Events 828
- MRI safety 4
- Nonsurgical Procedural Complications 118
- Overtreatment 4
- Psychological and Social Complications 126
- Second victims 6
- Surgical Complications 508
- Transfusion Complications 16
- Home Care 25
- Operating Room 453
- General Hospitals 1149
- Long-Term Care 59
- Outpatient Surgery 33
- Patient Transport 31
- Psychiatric Facilities 13
- Allied Health Services 14
- Complementary and Alternative Medicine 1
- Dentistry 8
- Anesthesiology 130
- Critical Care 300
- Dermatology 12
- Gynecology 47
- Cardiology 56
- Geriatrics 97
- Hematology 27
- Medical Oncology 102
- Nephrology 14
- Pulmonology 15
- Neurology 17
- Obstetrics 79
- Pediatrics 265
- Primary Care 114
- Radiology 76
- Nursing 379
- Palliative Care 4
- Pharmacy 331
- Family Members and Caregivers 27
Health Care Executives and Administrators
- Nurse Managers 449
- Quality and Safety Professionals
- Risk Managers 659
Health Care Providers
- Nurses 468
- Pharmacists 170
- Physicians 581
Non-Health Care Professionals
- Educators 393
- Engineers 118
- Media 10
- Policy Makers 147
- Patients 75
- Africa 5
- China 10
- Australia and New Zealand 169
- Central and South America 9
- United Kingdom 390
- Canada 187
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 119
- United States Federal Government 204
Search results for "Quality and Safety Professionals"
- Quality and Safety Professionals
van Boxtel CJ. Amsterdam, The Netherlands: IOS Press. ISSN: 09246479.
This quarterly journal supports high-quality medical practice with a particular focus on medical, ethical, and legal issues associated with risk and safety.
Web Resource > Multi-use Website
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
This coalition supports a network of patient safety professionals to facilitate dialogue, promote initiatives on eliminating wrong-site surgery, and improve medication safety.
The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary Report.
Hanlon C, Rosenthal J. Washington, DC: National Academy for State Health Policy; 2007.
This report summarizes a September 2007 symposium that brought together patient safety officials from 11 states. The meeting examined existing and emerging issues and also provided participants with policy solutions based on strategies successfully implemented in Pennsylvania.
Perspectives on Safety > Interview
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
Perspectives on Safety > Perspective
with commentary by John Whittington, MD, Patient Safety Programs, July 2006
One of the most important interventions is for hospital leadership to get the hospital's board involved with safety and quality. Not only does the board have fiduciary responsibility for the organization, but they have responsibility for quality and safety...
Landro L. The Wall Street Journal. March 22, 2006:A1.
This article reports on design guidelines that will require newly constructed hospitals to have only private rooms. Single-patient rooms may help reduce infection rates, improve recovery time, and enhance patient safety.
Harmon KT. Patient Safety & Quality Healthcare. March/April 2006;3:20-26.
The author, a former flight surgeon, describes safety concepts and guidelines that have minimized mishaps in naval aviation and discusses how these may be applied to health care.
Journal Article > Review
Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.
Koshy R. Transfusion. 2005;45(suppl 4):189S-205S.
The author examines technological advances for improving safety, such as bar coding, computerized physician order entry, radiofrequency identification, smart cards, decision support systems, and information technology standardization, and shares several strategies for implementation.
Journal Article > Study
Dowell D, Manwell LB, Maguire A, et al; MEMO Investigators. Healthc Q. 2005;8:suppl 2-8.
In this AHRQ-funded study, investigators conducted focus groups with patients to explore health care quality and safety issues. The authors conclude that patients can provide important insight for systems improvement and error reduction.
Meeting/Conference > District of Columbia Meeting/Conference
Society to Improve Diagnosis in Medicine. November 10-14, 2019; Hyatt Regency Washington, Washington DC.
Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This annual conference will focus on the theme, "Shaping Policy, Improving Practice" to discuss physical examination, patient partnership, and political advocacy as strategies to improve diagnosis. Featured speakers include Dr. Shantanu Agrawal, Dr. Helen Burstin and Dr. David Newman-Toker.
Meeting/Conference > Massachusetts Meeting/Conference
Harvard Medical School. November 6-7, 2019; Wyndham Boston Beacon Hill, Boston, MA.
This multidisciplinary conference will offer insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. The session will cover various topics of interest to professionals who work in the field, including radiation safety, care redesign, and leadership skill development.
Meeting/Conference > Maryland Meeting/Conference
Johns Hopkins Armstrong Institute for Patient Safety and Quality. November 5-6, 2019; Constellation Energy Building, Baltimore, MD.
Special or Theme Issue
Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533.
Resilience is an organizational characteristic that enables individuals and teams to adapt to chaotic conditions and reduce the potential for failure. This special issue explores the intersection between resilience and high reliability in a variety of theoretical and situational contexts such as in maternity care.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. July 30, 2019;(61):1-5.
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Journal Article > Commentary
ACR Committee on MR Safety; Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 2019 Jul 29; [Epub ahead of print].
The reliable adoption of safe practices in clinical and research imaging will reduce risks to diagnostic radiology patients. This guideline builds on existing recommendations as a response to the changing needs of magnetic resonance practitioners and their patients. Strategies to ensure clinical teams stay updated on safety issues in this environment include reviewing and updating guidelines as well as requiring magnetic resonance directors to undergo annual patient safety training.
Journal Article > Study
Influence of doctor–patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study.
Amelung D, Whitaker KL, Lennard D, et al. BMJ Qual Saf. 2019 Jul 20; [Epub ahead of print].
Despite many advances in cancer treatment, delays in cancer diagnosis cause substantial morbidity and mortality. System factors like difficulty obtaining appointments contribute to late cancer diagnoses. Timely cancer diagnosis also requires that patients and physicians communicate effectively about next steps in the workup of symptoms. This qualitative study recorded videos of patient–physician interactions and found that 31% of the time, doctors and patients did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment leads to missed follow-up testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer.
Society to Improve Diagnosis in Medicine.
Journal Article > Study
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
Holmgren AJ, Co Z, Newmark L, Danforth M, Classen D, Bates D. BMJ Qual Saf. 2019 Jul 18; [Epub ahead of print].
A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.
Journal Article > Study
Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.
Cifra CL, Houston M, Otto A, Kamath SS. Jt Comm J Qual Patient Saf. 2019;45:543-551.
Checklists allow health care teams to adhere to best practices. In a single institution's pediatric intensive care unit, a quality champion who prompted teams to discuss a safety checklist daily facilitated a reduction in urinary catheter days and length of stay. However, the patients cared for during the quality champion's tenure had lower illness severity.
Journal Article > Study
Association of residency work hour reform with long term quality and costs of care of US physicians: observational study.
Jena AB, Farid M, Blumenthal D, Bhattacharya J. BMJ. 2019;366:l4134.
In 2003, the Accreditation Council for Graduate Medical Education limited resident physician work hours to 30 hours in 1 shift and 80 hours in 1 week. These duty hour reforms were intended to enhance patient safety and trainee physician well-being. However, some have expressed concern that physicians who train for fewer hours will leave residency less skilled and ultimately provide lower quality care. Investigators assessed whether attending internists who trained with duty hour restrictions differed after residency in terms of their Medicare patients' mortality, readmissions, or costs when compared with internists who trained with unlimited duty hours. They found no difference in quality or cost between the two physician groups. Although other studies have concluded that duty hours have not adversely affected clinical or safety outcomes in residency, this study extends that finding to physicians' subsequent practice. Duty hour restrictions have consistently been associated with improved resident physician well-being. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.