Narrow Results Clear All
- Communication Improvement 19
- Culture of Safety 21
- Education and Training 19
Error Reporting and Analysis
- Error Reporting 28
- Human Factors Engineering 5
Legal and Policy Approaches
- Regulation 23
- Logistical Approaches 4
- Policies and Operations 3
Quality Improvement Strategies
- Benchmarking 13
- Research Directions 3
- Specialization of Care 2
- Teamwork 3
- Technologic Approaches 15
- Transparency and Accountability 1
- Device-related Complications 3
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 4
- Medical Complications 15
- Medication Safety 18
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 5
- Surgical Complications 10
- Transfusion Complications 1
- Internal Medicine 27
- Nursing 1
- Pharmacy 3
- Family Members and Caregivers 3
- Health Care Executives and Administrators 104
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 72
- Patients 15
- Australia and New Zealand 2
- Europe 25
- Canada 5
Search results for "Legal and Policy Approaches"
- Legal and Policy Approaches
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School; September 2018. ISBN: 9781909029880.
Regulation and accreditation programs are controversial approaches to improve safety. This report provides a framework developed to analyze the quality improvement inspection process in the United Kingdom. Investigators applied eight factors to examine how regulation can result in care delivery changes. They found that the regulation process can help engage staff in identifying areas of concern and uncover issues like poor performance.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Boston, MA: National Patient Safety Foundation; March 2017.
A public health approach to patient safety could help drive improvement efforts. This report recommends that health care draw from successes targeting health care–associated infections to design medical error reduction programs from this perspective. The authors provide a structured method for leaders and policymakers to generate lasting change in patient safety.
Dekker S. Boca Raton, FL: CRC Press; 2016. ISBN: 9781472475787.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
This comprehensive policy brief emphasizes the importance of addressing diagnostic errors through health policy change. The report explores the role of missed and delayed diagnosis in malpractice claims and preventable harm to patients. The authors note the lack of attention to diagnosis in the seminal To Err is Human report. They outline several strategies to detect and characterize diagnostic errors, including patient and provider surveys, case review, voluntary reporting, claims review, audits, and trigger tools in electronic medical records. To enhance timely and accurate diagnoses, the report advocates for increasing research funding, greater government oversight, instituting formal diagnostic feedback mechanisms, and payment and medical education reform.
Institute of Medicine. Washington, DC: The National Academies Press; 2011. ISBN: 9780309218030.
This lecture features Kathleen Sebelius, Secretary of Health and Human Services (HHS), and a distinguished panel of guests discussing measures taken by HHS to drive innovation and progress in patient safety.
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3.
This report analyzes communication practices between emergency and primary care physicians and provides suggestions to improve and encourage meaningful communication.
Windwick B, Aubin D, Beard P, et al; Disclosure Working Group. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2011. ISBN: 9781926541389.
These national guidelines for Canadian health care providers serve as a tool for developing and implementing disclosure policies, practices, and training methods.
Youngberg BJ, ed. Sudbury, MA: Jones Bartlett; 2011. ISBN: 9780763774059.
This textbook discusses claims management, risk financing, and proactive risk reduction within the context of patient safety improvement.
Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10-281.
Turney S, Evans EW, Callaway E, et al. Englewood Cliffs, CO: Medical Group Management Association; 2009.
This white paper discusses development of safety culture, policies, and administrative roles that can support patient safety improvement in physician practices and other ambulatory settings.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Disclosure of unanticipated events: creating an effective patient communication policy (part 2 of 3).
Chicago, IL: American Society of Healthcare Risk Management; 2003.
The process for crafting a policy to support effective disclosure initiatives is reviewed. Discussion includes a summary of the key document elements and highlights legal considerations.
Sharpe VA. Hasting Center Rep. 2003;33(suppl):S1-S20.
The results of a two-year Hastings Center project to elucidate ethical concerns that affect the dialogue in developing effective patient safety policies.