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- Communication Improvement 1
- Education and Training 3
- Error Reporting and Analysis
- Human Factors Engineering 4
- Legal and Policy Approaches 6
- Quality Improvement Strategies 3
- Technologic Approaches 2
- Transparency and Accountability 2
- Device-related Complications 4
- Diagnostic Errors 1
- Drug shortages 1
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications 1
- Surgical Complications 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 12
- Health Care Providers 10
- Non-Health Care Professionals 6
- Patients 7
Search results for "Governmental Reporting"
- Active Errors
- Governmental Reporting
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.
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Koba M. Fortune. January 6, 2015.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Journal Article > Study
Sevdalis N, Jacklin R, Arora S, Vincent CA, Thomson RG. J Eval Clin Pract. 2010;16:1276-1281.
Journal Article > Study
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.
Journal Article > Study
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.
North Carolina law requires all nursing homes to report medication errors, as discussed in a prior article. Analysis of medication error reports submitted to this Web-based error reporting system revealed that most of the serious errors occurred during evening shifts and involved drugs given to the wrong patient.
Journal Article > Study
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
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.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.
Journal Article > Commentary
Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.
Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Washington DC: National Quality Forum; 2010.
The landmark Institute of Medicine (IOM) report, To Err Is Human, called for states to publicly report never events—medical errors that resulted in death or severe disability. This National Quality Forum publication evaluates the current status of state reporting systems 10 years after the IOM report, and summarizes the strengths and limitations of current public reporting initiatives. To date, 28 states maintain some type of reporting system, primarily tracking never events and health care–associated infections. However, states vary significantly in their implementation of these systems, requirements for reporting errors, and regulations regarding analysis and follow-up of errors, limiting the effect of reporting systems on improving patient safety. An AHRQ WebM&M perspective discusses the challenges and opportunities faced by current state reporting systems.
Journal Article > Study
Repeat medication errors in nursing homes: contributing factors and their association with patient harm.
Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.
This study found that 37% of medication errors were repeated one or more times in nursing home settings, with wrong dosage and wrong administration as the most frequent causes. While the absolute harm rates were small, repeat errors were twice as likely to be harmful to patients compared to non-repeated ones.
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.