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- Root Cause Analysis
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.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Perspectives on Safety > Interview
Accreditation and Regulation, April 2009
Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent standard setting and accrediting organization in health care in the United States and, increasingly, the world. Over the course of his notable career, Dr. Chassin, an emergency medicine physician, has held a variety of key positions, including New York State Health Commissioner and chair of the department of health policy at Mt. Sinai. He has published several seminal papers and was a member of the team that authored the IOM report, "To Err Is Human." We asked him to speak with us about his role at The Joint Commission, as well as future directions for the organization.
Journal Article > Commentary
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
The authors outline the practical considerations in developing a medication patient safety program, including establishing a blame-free environment and collecting and analyzing error data.
Journal Article > Commentary
McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.
Gaul GM. The Washington Post. July 29, 2005:A06.
This article presents the newly passed Patient Safety and Quality Improvement Act of 2005 in comparison to mandatory, state-based reporting initiatives.