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- Communication Improvement 2
- Culture of Safety 3
- Education and Training 6
- Error Reporting and Analysis 14
- Human Factors Engineering 2
Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 10
- Technologic Approaches 4
- Device-related Complications 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 7
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 3
Search results for "Regulation"
Rozovsky FA, Woods JR Jr, eds. San Francisco, CA: Jossey Bass; 2011. ISBN: 9781118086995.
This well-referenced and up-to-date handbook covers many of the regulatory and operational issues relevant to developing an organizational patient safety program. It is particularly strong in the areas of regulatory compliance, error reporting, and disclosure. Patient safety officers and risk managers are likely to find it of considerable interest.
Contribution of Governance to Patient Safety Initiatives in Australia, England, New Zealand and the United States.
Baker R. Toronto, ON, Canada: Health Canada; 2007.
The author shares analysis of the governance of patient safety in four countries with safety initiatives.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; November 2004.
Six states have enacted legislation to support the development of state patient safety centers to address the problem of medical errors. This report examines the various models applied in these states to design, administer, and monitor the centers.
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.
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.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
The 10 years since the release of the Institute of Medicine's To Err Is Human report have yielded some improvements in patient safety, but this Consumers Union report reminds clinicians and consumers alike that much work remains to be done. As the report notes, preventable safety problems such as medication errors and health care–associated infections still cause significant morbidity and mortality, despite the existence of effective preventive strategies. The report advocates for standardized measurement and public reporting of errors and calls for tighter accreditation standards for health care professionals.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.
The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of Inspector General; January 2008. Report No. OEI-02-06-00310.
This report examines the operation and staffing of 109 physician-owned specialty hospitals and identifies shortcomings in the availability of emergency services.
London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634093.
This report shares the results of the British National Patient Safety Agency effort to reduce medical error and found that safety wasn't always given the priority necessary to drive change and that data collection efforts could still be improved.
Shea KK, Shih A, Davis K. New York, NY: The Commonwealth Fund; July 2007.
This report discusses results of a national survey regarding how to improve the safety and quality of health care. Respondents supported greater adoption of health information technology, public reporting of performance on quality measures, and more oversight.
Callender AN, Hastings DA, Hemsley MC, Morris L, Peregrine MW. Washington, DC: US Department of Health and Human Services Office of the Inspector General; June 29, 2007.
This report outlines the fiduciary and corporate responsibilities of board members to support quality and safety in hospitals and provides questions to help them examine the scope of these efforts in their organizations.
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.
Washington, DC: United States Government Accountability Office; June 2006. Publication GAO-06-416.
This government report found that the clinical laboratory survey process is flawed, allowing safety requirements to be bypassed.