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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 9
- Human Factors Engineering 5
- Legal and Policy Approaches 3
- Quality Improvement Strategies 7
- Specialization of Care 1
- Device-related Complications
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 2
- Medical Complications 10
- Medication Safety 5
- Nonsurgical Procedural Complications 2
- Surgical Complications 7
- Europe 2
- North America 16
Search results for "Device-related Complications"
- Device-related Complications
Silver Spring, MD: US Food and Drug Administration; April 2018.
Reliable use of medical devices is an important contributor to safe health care delivery. This report describes the US Food and Drug Administration's plan to raise awareness of problems with devices in the field, develop new devices with better safety and cybersecurity protections, and enhance innovation and the product life cycle through regulation.
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
Applying human factors engineering to examine mistakes associated with medical device use can lead to valuable learning opportunities. This publication discusses equipment use errors and provides information about utilizing root cause analysis (RCA) to identify weaknesses in device design that enable those mistakes. The book includes examples of RCAs to illustrate how the method can uncover flaws that contribute to error in various situations.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
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.
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.
Tallahassee, FL: Florida Hospital Association; August 2013.
Chicago, IL: Health Research & Educational Trust; July 2013.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
This monograph provides guidance, tools, and techniques for hospitals to help decrease central line–associated bloodstream infections.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
Center for Devices and Radiological Health. Bethesda, MD: Food and Drug Administration, US Dept of Health and Human Services; 2006.
This document provides background on hospital bed injuries, identifies potentially dangerous design flaws, and offers assessment tools to reduce entrapment incidents.