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- Review 2
- Study 8
- Slideset 1
- Book/Report 28
- Legislation/Regulation 1
- Newspaper/Magazine Article 78
- Toolkit 3
- Web Resource 20
- Communication Improvement 32
- Culture of Safety 9
- Education and Training 22
Error Reporting and Analysis
- Error Reporting 38
- Human Factors Engineering 14
- Legal and Policy Approaches 52
- Logistical Approaches 10
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 6
- Teamwork 3
- Clinical Information Systems 5
- Transparency and Accountability 5
- Device-related Complications 7
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 12
- Drug shortages 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 39
- Medication Safety 18
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 10
- Surgical Complications 20
- Transfusion Complications 3
- Surgery 5
- Nursing 4
- Pharmacy 4
- Family Members and Caregivers 14
- Health Care Executives and Administrators 40
Health Care Providers
- Nurses 3
- Physicians 11
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 14
- Canada 4
Search results for "Patients"
- General Internal Medicine
Journal Article > Study
Etchegaray JM, Ottosen MJ, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.
Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Journal Article > Commentary
Petronio S, Torke A, Bosslet G, Isenberg S, Wocial L, Helft PR. Perm J. 2013;17:73-79.
This piece describes a two-step model to help physicians disclose medical errors to patients and families.
Journal Article > Study
Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.
This study explored current practices related to the National Health Services' being open policy for communicating unintentional harm with patients and families.
Pear R. New York Times. September 23, 2012:A20.
The newspaper article discusses a proposed federal initiative for patients and families to report experiences with medical errors.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.
Web Resource > Multi-use Website
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The 2018 results are the sixth generation of the scores, which now include a medication error score. A related report from the Armstrong Institute examines avoidable death associated with grading hospitals.
Trew M, Nettleton S, Flemons W. Edmonton, AB, Canada: Canadian Patient Safety Institute; June 2012.
This publication describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organizations to enable such collaboration.
Golden, CO: HealthGrades Inc.; May 2012.
This report used Medicare hospitalization data from 2008–2010 to explore correlations between patient–provider communication and patient safety in high-performing hospitals in the United States.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
St Andrews, Scotland: Scottish Information Commissioner; February 21, 2012. Reference No: 201100433.
This report describes an investigation into a 5-year delay in action plans for critical incident reviews in Scotland.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
This white paper identifies drivers of patient-centered care, and provides tools to help organizations improve the patient and family experience.
Journal Article > Commentary
Condition concern: an innovative response system for enhancing hospitalized patient care and safety.
Baird SK, Turbin LB. J Nurs Care Qual. 2011;26:199-207.
This commentary describes the design, launch, and impact of a program that enabled patients and families to report clinical care and safety issues.
Reed K, May R. Golden, CO: Health Grades, Inc; 2010.
This report analyzed Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator data from 2006–2008 to identify pediatric patient safety incidence rates.