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- Study 2
- Book/Report 4
- Legislation/Regulation 2
- Newspaper/Magazine Article 4
- Toolkit 1
- Web Resource 3
- Award 1
- Press Release/Announcement 1
- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Technologic Approaches 2
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 5
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Governmental Reporting"
- Governmental Reporting
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.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
Rojas-Burke J. Oregonian. January 30, 2007:B01.
This article reports on results from the first round of error data reported to the Oregon Patient Safety Commission voluntary reporting program.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Rau J. Kaiser Health News. July 6, 2017.
System failures contribute to recurring problems in health care environments. This news article spotlights how lack of follow-up or action related to inspection reports that have uncovered factors in long-term care facilities that contribute to inadequate care can enable poorly performing nursing homes to remain in operation.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Journal Article > Study
Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.
Pakyz AL, Edmond MB. Infect Control Hosp Epidemiol. 2013;34:780-784.
Twenty-seven states mandate reporting of central line–associated bloodstream infections. However, these regulations do not appear to have any effect on infection rates.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
Federal Register. February 12, 2008;73:8112-8183.
These proposed rules seek to support the implementation of portions of the Patient Safety and Quality Improvement Act of 2005 including how entities are defined as a patient safety organization (PSO) and how PSOs will collect and protect safety incident data. The comment period on the proposed rules is now closed.
Ostrom CM. Seattle Times. October 23, 2007:A1.
This article discusses a conflict that has arisen between the Washington State Hospital Association and state lawmakers regarding public disclosure of incident reporting data.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
Journal Article > Study
Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia.
Charles A, Ranson D, Bohensky M, Ibrahim JE. Int J Qual Health Care. 2007;19:232-36.
The researchers reviewed inpatient mortality at two Australian hospitals and found that more than half of deaths that met the coroner's reporting criteria were not reported. Such under-reporting limits the ability to detect preventable deaths.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Journal Article > Commentary
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.
Journal Article > Commentary
Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.
Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.
The author presents a legal discussion on public access to physician information, arguing that Congress should allow consumers to access certain information while still protecting error information in order to promote error reporting.