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- Patient Safety Primers 1
- WebM&M Cases 4
- Perspectives on Safety 3
- Commentary 11
- Review 1
- Study 50
- Audiovisual 6
- Book/Report 28
- Legislation/Regulation 2
- Newspaper/Magazine Article 21
- Special or Theme Issue 4
- Glossary 1
- Toolkit 9
- Web Resource 31
- Meeting/Conference 6
- Press Release/Announcement 2
- Communication Improvement
- Culture of Safety 4
- Education and Training 67
- Error Reporting and Analysis 15
- Human Factors Engineering 16
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 28
- Research Directions 2
- Specialization of Care 4
- Teamwork 3
- Clinical Information Systems 9
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 17
- Identification Errors 6
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 40
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Surgical Complications 6
- Internal Medicine 31
- Pediatrics 11
- Primary Care 16
- Nursing 2
- Pharmacy 31
- Family Members and Caregivers 7
- Health Care Executives and Administrators 69
Health Care Providers
- Nurses 5
- Pharmacists 14
- Physicians 18
Non-Health Care Professionals
- Educators 30
- Patients 64
- Australia and New Zealand 1
- Europe 6
- Canada 1
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 30
- United States Federal Government 33
Search results for "Health Literacy Improvement"
- Health Literacy Improvement
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Journal Article > Commentary
Alton M, Mericle J, Brandon D. Adv Neonatal Care. 2006;6:112-119.
The authors describe the implementation of a safety program to instill a culture of safety following a high-profile sentinel event.
Perspectives on Safety > Perspective
with commentary by Nancy C. Elder, MD, MSPH, Outpatient Safety, May 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Rockville, MD: Agency for Healthcare Research and Quality. March 6, 2006.
This podcast features an interview with AHRQ Director Carolyn Clancy on educating clinicians and patients and families about patient safety.
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.
Web Resource > Government Resource
US National Library of Medicine, National Institutes of Health.
This directory of consumer materials helps patients find information on how to support their own safe care.
Lunzer Kritz F. Woman's Day. November 15, 2005;69:42,46,48.
This article reports on several medical technologies and procedures designed to enhance patient safety and provides suggestions on how consumer awareness can facilitate their safety.
Journal Article > Study
Hibbard JH, Peters E, Slovic P, Tusler M. Med Care Res Rev. 2005;62:601-616.
This AHRQ-funded study conducted interviews with nearly 200 participants to assess their likelihood of engaging in preventive actions to avoid medical errors. The 14 preventive actions discussed were from a list generated by an AHRQ publication as well as from focus groups conducted by CMS. The investigators discovered significant variability in both the perceived effectiveness of a given action and the likelihood of taking that action. The authors advocate for greater attention to educating patients about their own safety, along with broader safety issues.
Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Washington, DC: National Quality Forum; 2005.
In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.
Chase M. Wall Street Journal. August 16, 2005:D1.
This article reports that in other countries, some medications have the same brand name as U.S. medications but contain completely different ingredients, often for treatment of different conditions. To avoid mix-ups, the article cautions against purchasing prescription medications abroad.
Young D. Am J Health Syst Pharm. 2005;62:1340-1342.
This article summarizes comments made at the second meeting of the Committee on Identifying and Preventing Medication Errors. Topics covered include teamwork, engaging patients, medication reconciliation, access to information, and hospital design.
Journal Article > Commentary
The Risk Management Reporter. June 2005;24:1,3-7.
This commentary provides a definition of patient-centered care, lists potential impediments to implementation, and highlights several successful initiatives in acute care hospitals.
Cases & Commentaries
- Spotlight Case
- Web M&M
Alan Forster, MD, MSc; December 2004
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
Tools/Toolkit > Fact Sheet/FAQs
American College of Surgeons.
This brochure provides information for patients to help ensure that their surgery is performed on the correct part of the body.
Tools/Toolkit > Fact Sheet/FAQs
Huntingdon Valley, PA: Institute for Safe Medication Practices; 2004.
This booklet provides instructions, recommendations, and safe tips for patients in the hospital, at their doctor's office, or at home. Additional readings are included.
Berntsen KJ. Westport, CT: Praeger; 2004. ISBN: 0275982300.
The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relevant stories from patients and tips to minimize opportunities for failure.