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- Epidemiology of Errors and Adverse Events
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Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; February 2014. Report No. OEI-06-11-00370.
This report from the Office of the Inspector General examines the nationwide incidence of adverse events in skilled nursing facilities among the Medicare population. Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event, and more than half were preventable. These results mirror previous studies documenting an overall poor level of safety culture in nursing homes. More than half of those who experienced harm were readmitted to the hospital. The report outlines recommendations, including raising awareness of safety concerns in this setting and instructing surveyors who inspect nursing homes to evaluate patient safety practices. These findings emphasize the importance of focusing outside acute care settings in order to advance patient safety by improving systems of care and by aligning accreditation and payment structures. A past AHRQ WebM&M interview discussed unique issues surrounding patient safety in the nursing home population.
Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678.
The Crossing the Quality Chasm report provided a framework to improve quality and safety in health care. This publication draws on the six aims for quality outlined in the report to review core competencies, knowledge, and attitudes for safe nursing care. Topics covered include nurses as leaders, teamwork, and patient-centered care.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 1-year period.
Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277.
This publication provides information about the role of nurses in health care safety and explores how organizational dynamics, leadership, and hazard identification can affect the abilities of frontline nurses to deliver safe care. Helpful resources such as checklists, sample control plans, and review exercises are also included.
Rosenthal MM, Sutcliffe KM, eds. San Francisco, CA: Jossey-Bass; 2002. ISBN: 078796395X.
Opening with a review of lessons learned since the Harvard Medical Practice Study (HMPS), this book explores the issues involved in identifying solutions for improving patient safety. Experts in the field provide unique perspectives on nursing, the ''code of silence,'' and mindfulness. The editors close with an essay on driving action in the field through research and an action agenda.