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Search results for "State Governments and Agencies"
- Non-Health Care Professionals
- State Governments and Agencies
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Special or Theme Issue
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
Web Resource > Government Resource
Center for Health Information and Analysis.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October 2016.
This annual publication provides data on adverse events reported to the Connecticut Department of Public Health. The most recent report discusses an analysis of the 456 incidents submitted in 2015, which represents a slight decrease. The most common adverse events reported were pressure ulcers and fall-related injuries or deaths. Past reports are also available.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
Jefferson City, MO: Center for Patient Safety; June 11, 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report analyzes trends present in reports submitted to the PSO in 2018. Medication errors, falls, and health care–acquired infections were frequently reported. The material discusses reasons for these events, shares lessons learned, and points to resources to aid organizations in reducing conditions that enable reportable occurrences.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Web Resource > Multi-use Website
Beth Israel Deaconess Medical Center and Massachusetts Medical Society.
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
Patients are increasingly being asked to assume a role in ensuring their own safety. This report explores patients' adoption of practices meant to help improve their safety and found that 8 of the 10 suggested tactics are actively used by health care consumers in Pennsylvania.
Web Resource > Multi-use Website
Michigan Pharmacists Association.
Wakefield, MA: Quality and Patient Safety Division, Massachusetts Board of Registration in Medicine.
This free newsletter provides information on quality and patient safety initiatives in Massachusetts.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Tallahassee, FL: Florida Hospital Association; August 2013.
Web Resource > Government Resource
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them.
Journal Article > Commentary
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
Journal Article > Study
Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.