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- Communication Improvement 5
- Education and Training 1
- Error Reporting and Analysis 7
- Legal and Policy Approaches 8
- Quality Improvement Strategies 4
- Teamwork 1
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 2
- Medical Complications 4
- Medication Safety 1
- Nonsurgical Procedural Complications 3
- Surgical Complications 9
Search results for "Patients"
- Outpatient Surgery
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
Tools/Toolkit > Fact Sheet/FAQs
Rosemont, IL: American Academy of Orthopaedic Surgeons.
Patient engagement is a promising strategy for error reduction and has become a priority of influential regulatory and governmental organizations. This Web site offers tips to help patients improve their safety, including bringing a friend or family member to appointments, asking questions prior to surgery, and keeping an accurate medication list.
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.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Cohen E. CNN. October 15, 2012.
This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.
Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.
This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.
Clancy C. Navigating the Health Care System. Rockville, MD: Agency for Healthcare Research and Quality; May 2010.
This video features Dr. Carolyn Clancy sharing tips with patients to encourage them to contribute to their safe medical care.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
Landro L. Wall Street Journal. February 18, 2009:D1.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
Web Resource > Multi-use Website
2410A Hyde Park Road, Jefferson City, MO 65109.
The Missouri Center for Patient Safety is dedicated to improving patient safety in Missouri by applying evidence-based methods and best practices. The private, not-for-profit corporation was established by the Missouri State Medical Association, the Missouri Hospital Association, and Primaris, a quality improvement organization.
Brooks A. New York Times. June 14, 2005:F5.
This article provides a brief review of safety concerns associated with free-standing surgical centers.