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Peter Lindenauer, MD, MSc; November 2006
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
Perspectives on Safety > Interview
Surgical Errors, September 2007
Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.
Journal Article > Commentary
When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?
Naessens JM, Culbertson RA, Lefante JJ, Campbell CR. Qual Manag Health Care. 2007;16:153-165.
The authors propose criteria for classifying a multi-location hospital as a single reporting entity and provide a case study to assess these criteria.
The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.
This report calls for providing "safe, well-coordinated, accessible, and efficient" care through five key steps: expanding health insurance coverage, implementing evidence-based patient safety and quality interventions, increasing use of health information technology, public reporting of safety and quality measures, and rewarding achievement in quality through "pay-for-performance." The authors ascribe the current quality problems in the U.S. health care system to system failures, including misaligned payment incentives, inadequate motivation to challenge the status quo, inadequate information systems, duplicative regulatory systems, and an overemphasis on autonomy.
Journal Article > Study
McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.
This study shares the efforts of six different health care organizations in implementing interventions to improve patient safety. All of the organizations identified culture change as the most important factor in promoting safety, though the mechanisms to achieve such change differed. The authors provide a contextual background of safety culture, including definitions, attributes, and strategies to approach the issue, and present a detailed account of each case study. They point out that creating a desired culture of safety may be both foundational to safety efforts and also very challenging to accomplish. The shared stories offer a practical perspective regarding the issues that face most organizations committed to improving patient safety.