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Approach to Improving Safety
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Book/Report
Patient Safety Culture Report: Focusing on Indicators.
Utrecht, Netherlands: European Network for Patient Safety; 2010.
This report identifies care process and outcome indicators in the European Union and describes how the indicators relate to patient safety culture.
Journal Article > Commentary
Making patient safety the centerpiece of medical liability reform.
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.
Newspaper/Magazine Article
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
Award
2013 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.
Joint Commission. January 27, 2014.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2013 honorees are Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health, from Minnesota; Anthem Blue Cross, National Health Foundation, Hospital Association of Southern California, Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, from California; Vidant Health, of North Carolina; and Gail L. Warden, in Michigan. The awards were presented at the National Quality Forum's Annual Conference on February 13, 2014, in Washington, DC.
Book/Report
Tennessee Center for Patient Safety.
Nashville, TN.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Web Resource > Multi-use Website
European Union Network for Patient Safety and Quality of Care.
PaSQ Coordinating Secretariat. HAS, Haute Autorité de Santé. La Plaine Saint-Denis Cedex, France.
This organization aims to promote implementation of recommended patient safety practices in European Union member states with a goal of developing a collaborative network to ensure long-term safety and quality improvement.
Newspaper/Magazine Article
Sterile compounding tragedy is a symptom of a broken system on many levels.
ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.
This piece reviews risks associated with the use of compounding pharmacies and recommends that legislative oversight can improve medication safety.
Bibliography
The Patient Safety Perspective: Health Information and Resources Online and In Print, Revised Edition.
Burt HA. Chicago, IL: Medical Library Association; 2012.
This bibliography introduces patient safety and provides information about relevant Web sites, publications, and organizations.
Web Resource > Database/Directory
AdvocateDirectory.org.
Columbia, SC: Mothers Against Medical Error; 2010.
This directory provides a listing of organizations and individuals dedicated to safe provision of health care.
Web Resource > Multi-use Website
Canadian Patient Safety Institute.
10235 101 Street, Suite 1414, Edmonton, AB, Canada T5J 3G1.
The Canadian Patient Safety Institute (CPSI) fosters collaboration between governments and stakeholders in developing patient safety initiatives. This Web site provides tools for health care professionals and patients.
Audiovisual
Chasing Zero: Winning the War on Healthcare Harm.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Award
Announcing 2009 Leapfrog top hospitals.
Washington, DC: Leapfrog Group; December 4, 2009.
This news announcement highlights the 45 urban, children's, and rural hospitals recognized for highly efficient performance and continuous improvement in patient safety based on the 2009 Leapfrog Hospital Survey results.
Book/Report
How Safe Is Your Hospital?
Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.
This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiveness, and patient experiences and found wide variation in the scores.
Journal Article > Commentary
What cannot be said on television about health care.
Emanuel EJ. JAMA. 2007;297:2131-2133.
The author discusses how changes in language used to describe health care reflect a shifting public perception of the US health care system. This shift involves increasing recognition that errors do occur and that the health care system is flawed.
Grant
Canadian Patient Safety Institute announces recipients of first research funding competition.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.
Newspaper/Magazine Article
'Health courts' offer cure.
USA Today. July 4, 2005.
This editorial supports legislation such as the Fair and Reliable Medical Justice Act, which calls for special courts to evaluate medical malpractice cases.
Legislation/Regulation > Federal Legislation
Fair and Reliable Medical Justice Act.
S 1337, 109th Cong, 1st Sess (Mt 2005).
This bill was introduced in the U.S. Senate to encourage alternatives to the current medical malpractice system (by creating a "health care court") and to promote early disclosure and resolution of medical errors.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...