Narrow Results Clear All
- Study 3
- Audiovisual 1
- Book/Report 6
- Legislation/Regulation 1
- Newspaper/Magazine Article 16
- Special or Theme Issue 3
- Toolkit 4
- Web Resource 11
- Press Release/Announcement 1
- Communication between Providers 21
- Culture of Safety 2
- Education and Training 11
- Error Reporting and Analysis 10
- Human Factors Engineering 6
- Legal and Policy Approaches 5
- Logistical Approaches 4
- Quality Improvement Strategies 10
- Specialization of Care 3
- Teamwork 5
- Technologic Approaches 6
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 8
- Identification Errors 6
- Medical Complications 1
- Medication Safety 10
- MRI safety 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 1
- Surgical Complications 5
- Family Members and Caregivers 1
- Health Care Executives and Administrators 29
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 13
- Patients 3
Search results for "State Governments and Agencies"
- Communication Improvement
- 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.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
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.
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
Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Special or Theme Issue
Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
PA-PSRS Patient Saf Advis. September 2009;6:93-97.
This article reports on failures surrounding critical test results and describes mechanisms to standardize communication and reduce patient harm.
Journal Article > Study
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Web Resource > Government Resource
Indiana State Department of Health.
This Web site provides background and information on Indiana's statewide incident reporting initiative.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Harrisburg, PA: Patient Safety Authority and Pennsylvania Patient Safety Reporting System; 2007.
This report compiles a series of interviews with patient safety officers on their role, the support needed to fulfill that role, and strategies for measuring improvement.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
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.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Patient Safety Initiative Alert. Trenton: New Jersey Department of Health and Senior Services; May 2006.
This announcement describes a near miss involving sandbags filled with metal shot instead of sand.
PA-PSRS Patient Saf Advis. March 2006;3:13-19.
This article addresses strategies for minimizing patient safety risks related to interactions with health care industry representatives, as well as the role they can play in promoting safety.
Journal Article > Study
Durbin J, Hansen MM, Sinkowitz-Cochran R, Cardo D. Am J Infect Control. 2006;34:25-30.
The investigators surveyed health care providers to determine their perceptions on patient safety in the health care system. They found that clinicians believed systemwide interventions and stronger patient involvement would improve safety.
Partnership for Health and Accountability. Marietta, GA: Georgia Hospital Association Research and Education Foundation; 2004.
In this 55-minute video, a medical ethicist, a hospital risk manager, and two health care attorneys review three clinical vignettes involving medical error. The video also presents communication techniques that health professionals can use to show empathy when discussing error with patients and families.
Tools/Toolkit > Fact Sheet/FAQs
Huntingdon Valley, PA: Institute for Safe Medication Practices; 2004.
This booklet provides instructions, recommendations, and safe tips for patients in the hospital, at their doctor's office, or at home. Additional readings are included.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.
Tools/Toolkit > Toolkit
This four-chapter report defines "health literacy" and provides strategies for states to address existing educational gaps. It outlines the existing activities of interested stakeholders and summarizes the findings of a survey conducted by the Council on State governments. The report ultimately offers supportive tools for state policy makers to clarify relevant issues in their own states.