Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 5
- Commentary 18
- Review 3
- Study 28
- Slideset 1
- Book/Report 51
- Legislation/Regulation 6
- Newspaper/Magazine Article 155
- Special or Theme Issue 5
- Toolkit 1
- Web Resource 44
- Award 1
- Grant 1
- Meeting/Conference 1
- Press Release/Announcement 6
- Communication Improvement 70
- Culture of Safety 32
Education and Training
- Students 3
Error Reporting and Analysis
- Never Events 14
- Error Reporting 208
- Human Factors Engineering 19
Legal and Policy Approaches
- Regulation 28
- Logistical Approaches 5
- Policies and Operations 3
Quality Improvement Strategies
- Benchmarking 14
- Research Directions 2
- Specialization of Care 3
- Teamwork 4
- Clinical Information Systems 11
- Transparency and Accountability 15
- Device-related Complications 24
- Diagnostic Errors 27
- Discontinuities, Gaps, and Hand-Off Problems 15
- Drug shortages 2
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 17
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 40
- Nonsurgical Procedural Complications 8
- Psychological and Social Complications 24
- Surgical Complications 51
- Transfusion Complications 3
- Ambulatory Care 21
- General Hospitals 54
- Long-Term Care 5
- Outpatient Surgery 7
- Patient Transport 1
- Psychiatric Facilities 5
- Internal Medicine 79
- Pediatrics 15
- Nursing 7
- Palliative Care 1
- Pharmacy 16
- Family Members and Caregivers 35
- Health Care Executives and Administrators 134
Health Care Providers
- Nurses 6
- Physicians 28
Non-Health Care Professionals
- Media 10
- Australia and New Zealand 6
- Europe 31
- Canada 13
- United States of America 263
Search results for "Error Reporting and Analysis"
- Error Reporting and Analysis
Web Resource > Multi-use Website
Farnborough, Hampshire, UK.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Journal Article > Commentary
Schroeder AR, Duncan JR. JAMA Pediatr. 2016;170:1037-1038.
Overuse of CT scans can expose patients to levels of radiation linked to increased rates of cancer. Describing efforts to raise awareness of problems associated with using medical imaging in children, this commentary calls for more targeted work to standardize the process for this population to reduce overuse to ensure safer care for pediatric patients.
Roe S, King K. Chicago Tribune. February 10–13, 2016.
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports discusses the problem of drug interactions, including one patient's experience of severe harm and researchers' use of data mining to identify medication pairs linked to high-risk interactions. The series also includes a list of steps patients can take to reduce risk of harmful interactions between medicines they take.
Epstein H. The Atlantic. November 17, 2015.
Recent emphasis on diagnostic error has raised awareness of the problem. This magazine article discusses how the wide range of diseases to be considered by pediatricians and challenges associated with children's ability to recognize and describe their symptoms contribute to diagnostic complexity in this specialty.
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
Journal Article > Study
Herrin J, Harris KG, Kenward K, Hines S, Joshi MS, Frosch DL. BMJ Qual Saf. 2016;25:182-189.
This survey of acute care hospitals found significant variation for patient and family engagement activities. Most hospitals reported unrestricted visitor access, nearly two-thirds had formal error disclosure policies, and less than half had a patient advisory council. These findings demonstrate the gap between patient engagement recommendations and current hospital practice.
Boodman SG. The Atlantic. June 7, 2015.
Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses characteristics of the condition, contributing factors, challenges to diagnosing it, and strategies to reduce its incidence. A previous AHRQ WebM&M commentary describes the key diagnostic differences between delirium and dementia.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
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.
Hamill SD. Pittsburgh Post-Gazette. April 18, 2010:A1.
This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.
Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.
Gibson R, Singh JP. Washington, DC: Lifeline; 2003. ISBN: 089256112X.
Written by a program officer at the Robert Wood Johnson Foundation and a health economist, this book chronicles real stories of victims of medical mistakes. Written in a popular style and in an advocate's tone, experts may find the analyses of individual errors and discussion of policy implications a bit superficial; the book's major contribution is putting a human face on medical errors.
Audiovisual > Audiovisual Presentation
Producer: Partnership for Patient Safety & Risk Management Foundation. Chicago, IL: Partnership for Patient Safety; 2000.
This video, produced by the Partnership for Patient Safety and the Harvard Risk Management Foundation, presents a series of missteps involving a healthy obstetric patient and her unborn infant. Based on actual facts drawn from the experience of the Risk Management Foundation of the Harvard Medical Institutions, this 18-minute film illustrates the value of having a systems awareness in medicine. Deeper explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples for viewers. Parts 2 and 3 complete the video series.
Bogner MSE. Mahwah, NJ: Lawrence Erlbaum Associates; 1994.
This book, published well in advance of the Institute of Medicine report To Err is Human, includes chapters by a number of leaders in their fields on a wide range of topics related to patient safety. Chapters include the Foreword by James Reason, Lucian Leape's chapter on the preventability of medical injury, the chapter Operating at the Sharp End by Richard Cook and David Woods, the chapter on team performance in the operating room by Robert Helmreich and Hans-Gerhard Schaefer, the chapter on the handling of fatigue in various industries by Gerald Krueger, David Gaba's chapter on human error in dynamic domains, and the Afterword by Jens Rasmussen.
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.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
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.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.