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Approach to Improving Safety
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- Human Factors Engineering 10
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- Quality Improvement Strategies 25
- Specialization of Care 7
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Safety Target
- Device-related Complications 4
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- Discontinuities, Gaps, and Hand-Off Problems 10
- Fatigue and Sleep Deprivation 1
- Identification Errors 6
- Interruptions and distractions 1
- Medical Complications 13
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Clinical Area
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Medicine
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Target Audience
- Family Members and Caregivers 1
- Health Care Executives and Administrators
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Health Care Providers
62
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Non-Health Care Professionals
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Search results for "Health Care Executives and Administrators"
- Health Care Executives and Administrators
- State Governments and Agencies
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Web Resource > Multi-use Website
Safetyleaders.org
Texas Medical Institute of Technology.
Safetyleaders.org is a knowledge management system provided to hospital leaders and performance experts. Portions of the site are not accessible to individuals whose organizations are not actively involved in a collaborative project with the Texas Medical Institute of Technology, but the open-source material is valuable.
Web Resource > Government Resource
Betsy Lehman Center for Patient Safety and Medical Error Reduction.
Center for Health Information and Analysis.
The Betsy Lehman Center is an independent organization named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Newspaper/Magazine Article
Distractions in the operating room.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
Book/Report
CPS Annual Reports.
Jefferson City, MO: Center for Patient Safety; April 12, 2016.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report describes a Missouri PSO's activities in 2015 broken down by environments: long-term care; emergency medical services; home health and hospice; and hospitals, ambulatory surgical centers, and medical offices. The publication also summarizes breakdowns of data collected over 5 years.
Web Resource > Multi-use Website
Massachusetts Alliance for Communication and Resolution Following Medical Injury.
Beth Israel Deaconess Medical Center and Massachusetts Medical Society.
Communication-and-response programs emphasize early disclosure of adverse events and proactive attempts to resolve incidents. This Web site provides resources for a collaborative effort to teach hospitals about disclosing to patients who have experienced a medical error.
Newspaper/Magazine Article
Improvement of Pennsylvania healthcare consumers' awareness of patient safety.
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
Patients are increasingly being asked to assume a role in ensuring their own safety. This report explores patients' adoption of practices meant to help improve their safety and found that 8 of the 10 suggested tactics are actively used by health care consumers in Pennsylvania.
Web Resource > Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Children are often prescribed oral liquid medications due to difficulty swallowing tablets or capsules. This Web site provides resources for an initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead to medication errors.
Web Resource > Multi-use Website
Reducing Avoidable Readmissions Effectively (RARE) Campaign.
Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health.
This Web site hosts materials to help hospitals enhance discharge planning, medication management, patient and family engagement, care transition, and communication as elements of a state-wide collaborative to reduce readmissions. The program received a 2013 Eisenberg Award.
Newsletter/Journal
FIRST Do No Harm.
Wakefield, MA: Quality and Patient Safety Division, Massachusetts Board of Registration in Medicine.
This free newsletter provides information on quality and patient safety initiatives in Massachusetts.
Book/Report
Maryland Hospital Patient Safety Program Annual Report: Fiscal Year 2014.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; March 2015.
This annual report summarizes never events in Maryland hospitals over the previous year. In 2014, reported hospital-acquired infections and readmissions decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including standardizing processes and engaging hospital and departmental leaders in safety initiatives.
Newspaper/Magazine Article
Breakdowns in the medication reconciliation process.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Book/Report
HANYS' Report on Report Cards.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
Web Resource > Multi-use Website
Quality and Safety.
Florida Hospital Association.
This Web site offers information about quality improvement programs in Florida, including the Florida Surgical Care Initiative and the FHA Hospital Engagement Network.
Newspaper/Magazine Article
Oral medications inadvertently given via the intravenous route.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Newspaper/Magazine Article
Spotlight on electronic health record errors: errors related to the use of default values.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Book/Report
Five Years of Quality: Working Together to Improve Care.
Tallahassee, FL: Florida Hospital Association; August 2013.
This report outlines successful state initiatives to address safety concerns in health care, including readmissions, surgical complications, and central line–associated bloodstream infections.
Web Resource > Government Resource
Sentinel Event Program.
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Newspaper/Magazine Article
Distractions and their impact on patient safety.
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them.
Journal Article > Commentary
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
Special or Theme Issue
Handoff Communication Tools.
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.