Narrow Results Clear All
- Communication Improvement 35
- Culture of Safety 15
- Education and Training 18
Error Reporting and Analysis
- Error Reporting 22
- Human Factors Engineering 5
- Legal and Policy Approaches 15
- Logistical Approaches 2
Quality Improvement Strategies
- Benchmarking 10
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 9
- Transparency and Accountability 2
- Device-related Complications 3
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 5
- Fatigue and Sleep Deprivation 2
- Identification Errors 6
- Medical Complications 14
- Medication Safety 13
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 9
- Surgical Complications 13
- Transfusion Complications 1
- Internal Medicine 34
- Pharmacy 3
- Family Members and Caregivers 16
- Health Care Executives and Administrators 61
- Health Care Providers 72
Non-Health Care Professionals
- Media 4
Search results for "Patients"
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.
Hatch S. New York, NY: Basic Books; 2016. ISBN: 9780465050642.
Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.
Chicago, IL: Health Research & Educational Trust; 2015.
Patient and family advisor programs have been implemented in health care as a way to incorporate the experiences of consumers into safety improvement work. This guide provides a framework to help hospitals develop partnership initiatives that focus on advisor recruitment, education, and teamwork to enhance efforts to engage patients and families in this role.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
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.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.
Trew M, Nettleton S, Flemons W. Edmonton, AB, Canada: Canadian Patient Safety Institute; June 2012.
This publication describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organizations to enable such collaboration.
Golden, CO: HealthGrades Inc.; May 2012.
This report used Medicare hospitalization data from 2008–2010 to explore correlations between patient–provider communication and patient safety in high-performing hospitals in the United States.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
St Andrews, Scotland: Scottish Information Commissioner; February 21, 2012. Reference No: 201100433.
This report describes an investigation into a 5-year delay in action plans for critical incident reviews in Scotland.
Kurz M, Tobin WN. Chestnut Hill, MA: Medically Induced Trauma Support Services Inc.; 2011.
This publication reports on how to engage patients and families in improving patient safety.
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
This white paper identifies drivers of patient-centered care, and provides tools to help organizations improve the patient and family experience.
Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048.
This publication provides guidelines for disclosure and reveals tactics for effective communication following medical error.
Reed K, May R. Golden, CO: Health Grades, Inc; 2010.
This report analyzed Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator data from 2006–2008 to identify pediatric patient safety incidence rates.
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
Oakbrook Terrace, IL: The Joint Commission; 2010.
This report reveals how hospitals can improve communication, cultural competency, and patient-centeredness to enhance patient experience of care.
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.
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.
Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.
Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.
This report summarizes results from a conference of consumers, health care professionals, and administrative leaders about improving the health care system and advancing patient-centered care. Key recommendations include involving patients and families in health care leadership, through measures such as patient advisory councils and partnering with community organizations. The report also emphasizes the role of health literacy in providing patient-centered care.