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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.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
Journal Article > Commentary
SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. BMJ Qual Saf. 2016;25:986-992.
The rapid growth in literature on patient safety and quality improvement (QI) has been accompanied by controversy about how such studies should be conducted and reported. Influential leaders have argued that QI studies demand a different standard of evaluation than traditional biomedical research, given their complexity. A contrary argument notes that failure to rigorously evaluate such research could result in wasted resources and unanticipated consequences if poorly evaluated interventions are widely implemented. Developed by expert consensus, these guidelines provide a blueprint for reporting the results of QI studies. Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize reporting of safety and QI studies. In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors, and a public comment period. SQUIRE 2.0 improves the usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors in the initial document.
Audiovisual > Audiovisual Presentation
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014). (Testimony of Richard Griffin; Robert A. McDonald.)
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014). (Testimony of John James, PhD; Ashish Jha, MD, MPH; Tejal Gandhi, MD, MPH; Peter Pronovost, MD, PhD; Joanne Disch, PhD, RN; Lisa McGiffert.)
A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.
Legislation/Regulation > Government Resource
Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Draft Guidance.
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; April 24, 2013.
This draft guidance seeks to outline design elements that reduce errors associated with medication labels. The process for submitting public comments is now closed.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. September 6, 2006;(37):1-3.
This alert provides risk reduction strategies to help health care facilities prepare for a sudden loss of electrical power.
Federal Register. April 10, 2006;71:18039-18053.
The U.S. Food and Drug Administration (FDA) is proposing to amend good manufacturing practice to include several strategies for minimizing medical gas-related patient safety incidents. The proposal is open for public comment through July 10, 2006.
Legislation/Regulation > Congressional Testimony
Hearings before the House Insurance Committee of the Pennsylvania General Assembly. (April 22, 2004) (statement of James R. Combes, MD, senior medical advisor, HAP).
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide reporting initiative.