Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Hospitals"

1 - 20 of 879 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Apologies following an adverse medical event: the importance of focusing on the consumer's needs.

Allan A, McKillop D, Dooley J, Allan MM, Preece DA. Patient Educ Couns. 2015;98:1058-1062.

In this study, participants observed two video-recorded scenarios of a surgeon apologizing for an adverse event. Although apologies that focused on admissions of responsibility, expressions of regret, and offers of restitution were viewed positively, those that also explicitly accounted for the patient's perspective by understanding the impact on the patient and offering to address the harm in a meaningful manner were better received.

Journal Article > Study

Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013.

Hibbs BF, Moro PL, Lewis P, Miller ER, Shimabukuro TT. Vaccine. 2015;33:3171-3178.

Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System grew from 10 in the year 2000 to 4324 in 2013, potentially due to the introduction of new vaccines, increasingly complex vaccination schedules, and changes in reporting practices. The most common errors were dispensing vaccines at an inappropriate schedule or administering expired or incorrectly stored vaccines. One-fourth of reported errors caused an adverse health event, with 8% of these resulting in serious harm.

Journal Article > Study

How to make medication error reporting systems work—factors associated with their successful development and implementation.

Holmström AR, Laaksonen R, Airaksinen M. Health Policy. 2015;119:1046-1054.

A survey of 16 international medication safety experts identified the critical factors for improving the performance of medication error reporting systems. The recommendations focused on the operating environment of error reporting systems—for example, taking steps to improve safety culture—rather than the technical specifications of the systems.

Book/Report

2014 Guide to State Adverse Event Reporting Systems.

Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.

State reporting systems were advocated early in the patient safety movement as a way to enable learning from errors. This analysis of 27 state-level reporting programs highlights that while adverse event reporting has become more sophisticated since the previous survey, only one new program has launched since then. The authors emphasize the value of partnership, collaboration, and transparency in the work of the participating states. An AHRQ WebM&M perspective spotlights state reporting programs as mechanisms to augment patient safety.

Journal Article > Commentary

The development of the National Reporting and Learning System in England and Wales, 2001-2005.

Williams SK, Osborn SS. Med J Aust. 2006;184:S65-S68.

The authors describe lessons learned from a 4-year effort to develop and implement a national reporting system in the United Kingdom.

Journal Article > Commentary

Internally-developed online adverse drug reaction and medication error reporting systems.

Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.

The authors describe the development and use of an in-house, online reporting system.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

Journal Article > Study

Exploring strategies for reducing hospital errors.

McFadden KL, Stock GN, Gowen CR III. J Healthc Manag. 2006;51:123-136.

The authors surveyed health care quality directors on the perceived value of seven strategies for minimizing error. They found gaps in the perceived need versus the implementation of these improvement mechanisms.

Newspaper/Magazine Article

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

This article highlights a commentary published in JAMA by two leading experts in patient safety which summarizes the progress made since publication of the landmark To Err is Human report in 2000.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Journal Article > Study

Implications of electronic health record downtime: an analysis of patient safety event reports.

Larsen E, Fong A, Wernz C, Ratwani RM. J Am Med Inform Assoc. 2017 May 30; [Epub ahead of print].

When electronic health records are out of use, either for planned upgrades or because of unexpected malfunction, this downtime disrupts usual hospital workflow. This study conducted an automated text search to identify incident reports related to electronic record downtime and analyzed the selected reports. Electronic health record downtime led to issues with laboratory testing including specimen identification errors and delayed transmission of results. Medication administration errors were also prevalent during downtime. Researchers found that downtime could hinder patient identification and information availability, which may result in serious safety hazards. The authors advocate for development of more comprehensive downtime procedures to address safety concerns as well as more consistent adherence to existing procedures.

Journal Article > Study

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

Weingart SN, Weissman JS, Zimmer KP, et al. Int J Qual Health Care. 2017 May 24; [Epub ahead of print].

Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety concerns to the attention of health care systems. Only 37 errors were reported during the study period of 17 months; most reports did not involve patient harm. As with prior studies of patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes reported was problems with diagnosis or advice from a provider. These results demonstrate the feasibility of implementing an incident reporting system for patients and families, and they underscore the need to focus on diagnostic safety in outpatient settings. A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care.

Journal Article > Commentary

Applying lessons from social psychology to transform the culture of error disclosure.

Han J, LaMarra D, Vapiwala N. Med Educ. 2017 May 18; [Epub ahead of print].

Developing disclosure skills can help physicians manage and respond to errors and near misses. Discussing social psychology principles that influence effective disclosure, this commentary highlights cognitive biases and group decision making as factors that can negatively affect the disclosure process.

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

Book/Report

Report of the Announced Inspection of Medication Safety at the Midland Regional Hospital Tullamore, County Offaly.

Dublin, Ireland: Health Information and Quality Authority; May 2017.

Investigation reports help health care organizations identify areas in need of improvement. This report highlights weaknesses in one hospital's medication safety processes and provides suggestions to enhance governance structure, effort prioritization, pharmacy leadership, and patient education to drive safe medication delivery.

Newspaper/Magazine Article

Medicare failed to investigate suspicious infection cases from 96 hospitals.

Jewett C. Kaiser Health News. May 9, 2017.

The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.

Journal Article > Commentary

Increasing patient safety event reporting in an emergency medicine residency.

Steen S, Jaeger C, Price L, Griffen D. BMJ Qual Improv Rep. 2017;6:u223876.w5716.

Technical and psychological factors can affect adverse event reporting. This quality improvement report highlights an effort to enhance resident reporting in an emergency department. Residents were educated about incident reporting and participated in feedback sessions every 2 months to improve their familiarity with the reporting system as well as augment their knowledge regarding how and what should be reported. The number and quality of reports increased following the intervention.

Journal Article > Commentary

The tension between promoting mobility and preventing falls in the hospital.

Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.

This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.

Newspaper/Magazine Article

Secret data on hospital inspections may soon become public.

Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.

Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.

Newspaper/Magazine Article

Why are medical errors still a leading cause of death?

Headley M. Patient Saf Qual Healthc. April 5, 2017.

This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent them. Strategies discussed include reducing variation on measures collected and developing a culture of reporting.

Back to Top