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- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 4
Legal and Policy Approaches
- Technologic Approaches 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 1
Search results for "Regulation"
- Multi-use Website
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
This website disseminates information regarding an AHRQ-funded initiative to implement and evaluate medical liability reform improvements that support safe patient care.
Web Resource > Multi-use Website
American Society of Health-System Pharmacists.
This Web site provides a selection of materials and discussion groups to help hospital-based pharmacists improve medication safety.
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.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Audiovisual > Audiovisual Presentation
Washington, DC: Alliance for Health Reform; April 7, 2006.
This Webcast presents a panel discussion on the development of patient safety organizations as stipulated by the Patient Safety and Quality Improvement Act of 2005 and other developments in the safety movement. Panelists include several patient safety leaders, including Agency for Healthcare and Research Quality (AHRQ) director, Carolyn Clancy.