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Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
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.
Journal Article > Study
Halligan MH, Zecevic A, Kothari AR, Salmoni AW, Orchard T. J Patient Saf. 2014;10:192-201.
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.
Journal Article > Study
Strating MM, Nieboer AP, Zuiderent-Jerak T, Bal RA. BMJ Qual Saf. 2011;20:344-350.
This study provides insights into the development of a quality improvement collaborative, focusing on the importance of creating measurable and achievable targets.
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.
Washington, DC: National Quality Forum; September 2009.
This announcement provides background on the proposed 2010 effort to revise and expand the National Quality Forum list of never events.
Santell JP. Mater Manage Health Care. December 19, 2006;15:26-28, 30.
The author discusses the role that human error plays in the failure of technological solutions employed to minimize medical mistakes.