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- Governmental Reporting
- Patient Falls
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.
Journal Article > Study
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 1-year period.