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Search results for "Hospitals"

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Book/Report

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.

Newspaper/Magazine Article

Surgical checklists unused in 10% of hospitals, CMS data shows.

Clark C. HealthLeaders Media. July 24, 2014.

The Hospital Compare Web site has begun to publicly report which hospitals are using checklists, and the results are concerning. Investigating reasons behind these findings, this news piece offers insights from physicians into why checklists have not been universally implemented and highlights the importance of developing a culture of safety to drive improvement efforts.

Journal Article > Study

Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes.

Laschinger HK. J Nurs Adm. 2014;44:284-290.

This survey study of registered nurses found that bullying and other disrespectful behaviors in the workplace were associated with more reports of patient safety risks. A previous AHRQ WebM&M commentary explores the link between professionalism and patient safety.

Newspaper/Magazine Article

Your safer-surgery survival guide.

Consumer Reports. September 2013;78:31-41.

This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings of hospitals by state.

Newspaper/Magazine Article

Leapfrog hospital safety scores 'depressing.'

Clark C. HealthLeaders Media. May 9, 2013.

This news piece reports on a national evaluation of hospitals that found little improvement in safety in the profiled health care systems.

Journal Article > Study

Identification by families of pediatric adverse events and near misses overlooked by health care providers.

Daniels JP, Hunc K, Cochrane D, et al. CMAJ. 2012;184:29-34.

This study introduced a family-based system for reporting adverse events and discovered a different lens into potential safety issues.

Newspaper/Magazine Article

Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children.

ISMP Medication Safety Alert! Acute Care Edition. November 3, 2011;16:1-2.

Summarizing cases of accidental ingestion of syringe caps, small device parts, and dangerous liquids, this newsletter piece describes how to prevent such incidents.

Journal Article > Study

Reporting trends in a regional medication error data-sharing system.

Anderson JG, Ramanujam R, Hensel DJ, Sirio CA. Health Care Manag Sci. 2010;13:74-83.

Sharing voluntary medication error reports within a group of Pennsylvania hospitals resulted in increased reporting rates, but it was unclear if the increase in reports led to greater safety efforts.

Book/Report

Adverse Events in Hospitals: Public Disclosure of Information About Events.

Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.

This brief report analyzes information from state reporting initiatives, Patient Safety Organizations, and the Centers for Medicare and Medicaid Services regarding privacy practices and policies surrounding public disclosure of adverse events.

Journal Article > Study

Injury and death associated with incidents reported to the Patient Safety Net.

Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.

This study characterizes the types and severity of patient safety events at academic hospitals that were reported to a voluntary error reporting system.

Newspaper/Magazine Article

Sarasota Memorial Hospital reviewed after restrained patient dies.

Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.

This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.

Special or Theme Issue

SafetyNet: Lessons Learned from Close Calls in the OR.

AORN J. 2006;84(suppl 1):S1-S63.

This special issue includes a series of articles on SafetyNet, the Association of periOperative Registered Nurses (AORN) Web-based reporting system launched in 2004 as a part of its Patient Safety First initiative.

Web Resource > Multi-use Website

Center for Patient Safety.

2410A Hyde Park Road, Jefferson City, MO 65109.

The Missouri Center for Patient Safety is dedicated to improving patient safety in Missouri by applying evidence-based methods and best practices. The private, not-for-profit corporation was established by the Missouri State Medical Association, the Missouri Hospital Association, and Primaris, a quality improvement organization.

Cases & Commentaries

The 2-Week Itch

  • Web M&M

Michael R. Cohen, RPh, MS, ScD; April 2003

Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.

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