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- Communication Improvement 2
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 5
- Legal and Policy Approaches 10
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Transparency and Accountability 1
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 3
- Transfusion Complications 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators 7
- Health Care Providers 5
- Non-Health Care Professionals 8
- Patients 11
Search results for "North America"
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Rau J. Kaiser Health News. July 6, 2017.
System failures contribute to recurring problems in health care environments. This news article spotlights how lack of follow-up or action related to inspection reports that have uncovered factors in long-term care facilities that contribute to inadequate care can enable poorly performing nursing homes to remain in operation.
Gardner LA. PA-PSRS Patient Saf Advis. June 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Koba M. Fortune. January 6, 2015.
Aston G. Hosp Health Netw. September 9, 2014.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Cohn M. Baltimore Sun. July 26, 2014.
This news article reports weaknesses in a Maryland reporting program, including poor understanding about which errors should be reported and lack of regulations regarding disclosure. Limited public access to comprehensive incident reports and insufficient performance measurement hinder consumers' ability to select hospitals based on safety.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
May H. Salt Lake Tribune. August 18, 2008.
This article examines 2007 state health data on never events in the context of a label-related medical error that resulted in a recent death.
Ostrom CM. Seattle Times. October 23, 2007:A1.
This article discusses a conflict that has arisen between the Washington State Hospital Association and state lawmakers regarding public disclosure of incident reporting data.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Rojas-Burke J. Oregonian. January 30, 2007:B01.
This article reports on results from the first round of error data reported to the Oregon Patient Safety Commission voluntary reporting program.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
Ebright PR, Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment; September 2005:1-7.
This brief report discusses important issues for policy makers in developing a statewide incident reporting system.