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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.
Journal Article > Commentary
Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. BMJ. 2009;338:b1775.
This article describes the results from a group of international clinicians, researchers, and policymakers that identified undeveloped research areas in global patient safety.
Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.
This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.
Jt Comm Perspect. August 2010;30:6-7.
This newsletter article discusses the National Patient Safety Goals (NPSG) for 2011 and describes revisions of current NPSGs.
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.
Jt Comm Perspect. October 2009;29:1, 20-31.
This newsletter article provides an overview of the 2010 National Patient Safety Goals (NPSGs) and explains revisions made to the NPSGs to address concerns about the resources needed to meet the NPSG requirements and to allow organizations to focus on the most urgent issues. The revisions include clarifying or deleting some of the requirements.
Legislation/Regulation > Pennsylvania Legislation
The General Assembly of Pennsylvania. HB957 (2005).
This bill calls for a prohibition of mandatory overtime and limiting the work week to 12 hours a day or 60 hours a week for non-supervisory health care employees in Pennsylvania. It is presently under consideration by Pennsylvania's General Assembly.
Legislation/Regulation > Congressional Testimony
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations.
Testimony before the Permanent Subcommittee on Investigations of the Senate Committee of Governmental Affairs, 108th Cong, 1st Sess (June 11, 2003) (statement of Carolyn M. Clancy, MD).
In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.