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Approach to Improving Safety
- Communication Improvement 22
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Education and Training
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Error Reporting and Analysis
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Error Reporting
- Never Events 12
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Error Reporting
- Human Factors Engineering 5
- Legal and Policy Approaches 22
- Logistical Approaches 2
- Quality Improvement Strategies 32
- Specialization of Care 1
- Teamwork 5
- Technologic Approaches 10
Safety Target
- Device-related Complications 9
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 5
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 6
- Medical Complications 20
- Medication Safety 32
- MRI safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 9
- Surgical Complications 13
Clinical Area
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Medicine
69
- Surgery 5
- Nursing 3
- Pharmacy 4
Target Audience
Search results for "Error Reporting"
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Press Release/Announcement
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.
National attention has focused on efforts to address adverse drug events. This call for comments seeks insights regarding revisions to a 2014 action plan that highlighted how to reduce adverse drug events associated with anticoagulants, diabetes agents, and opioids. These proposed updates involve measures to apply in both the inpatient and outpatient environments to track adverse drug events. The opportunity to submit written comments is now closed.
Book/Report
Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.
Carson-Stevens A, Hibbert P, Williams H, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
Management and analysis of incident reporting data must be enhanced in order to realize the potential for learning and improvement from reporting activities. This publication explored primary care incidents reported in England and Wales over an 8-year period. Investigators found inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred. Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system improvements needed to optimize incident reporting as a patient safety improvement strategy.
Newspaper/Magazine Article
Measuring patient safety events: opportunities and challenges.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Legislation/Regulation > Government Resource
Patient Safety and Quality Improvement Act of 2005—HHS guidance regarding patient safety work product and providers' external obligations.
Agency for Healthcare Research and Quality. Fed Regist. 2016;81;32655-32660.
Patient Safety Organizations (PSOs) were formed with provisions to protect voluntarily submitted incident data to enhance transparency and learning from medical error. Despite those expectations, PSOs still have obligations to report certain situations to external organizations. This guidance aims to clarify what and when external reporting should take place for PSOs to remain in compliance with federal requirements while appropriately protecting incident data.
Book/Report
PHSO Review: Quality of NHS Complaints Investigations.
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.
Book/Report
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Tools to collect and disseminate performance data can help improve care. This publication outlines how organizations can apply evidence-based strategies when designing voluntary reporting systems that engage clinicians and enable continuous improvement.
Tools/Toolkit > Government Resource
Hospital inpatients' experiences: percentage of parents who reported how often providers prevented mistakes and helped them to report concerns.
Rockville, MD: National Quality Measures Clearinghouse; December 2015.
Parents can help to recognize and report problems that occur when their children receive inpatient care. This quality measure has been developed to assist hospitals in tracking how often clinicians prevent mistakes while providing care for pediatric patients and whether they inform parents about ways to report concerns.
Audiovisual > Audiovisual Presentation
Raising Concerns: Speaking Up About Patient Safety.
Health Education England. London, England: National Health Service; February 2015.
Staff willingness to speak up when they are concerned about unsafe behaviors and conditions is a hallmark of a safety culture. This video uses vignettes to demonstrate challenges to speaking up in health care, how open communication can prevent errors, strategies to raise concerns on the frontline, and the value of checklist use in supporting conversation.
Journal Article > Government Resource
Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.
Moran J, Scanlon D. Health Aff (Millwood). 2013;32:27-35.
The Leapfrog Group pioneered efforts to improve hospital quality by emphasizing adoption of evidence-based practices for safer care. Although adoption of the Leapfrog recommendations has not been shown to decrease inpatient mortality, it has been associated with improved quality of care in other areas. The Leapfrog Group targeted specific cities and states, asking hospitals within these regions to publicly report their implementation of the recommended practices in the Leapfrog Hospital Survey. This analysis of Leapfrog survey data found minimal improvement over time in two key Leapfrog recommendations: computerized provider order entry implementation and intensivist staffing of critical care units. These findings, according to the authors, may indicate that hospitals did not have a business case for investing in patient safety.
Web Resource > Multi-use Website
National Coordinating Council for Medication Error Reporting and Prevention.
U.S. Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) coordinates a nationwide campaign for medication error reporting and prevention. They promote recommendations broadly to colleges, schools, and state and national professional organizations and other entities.
Book/Report
Serious Reportable Events in Healthcare—2011 Update.
- Classic
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Web Resource > Government Resource
Partnership for Patients.
- Classic
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.
Web Resource > Multi-use Website
EHR Event.
PDR Secure, Inc.
This Web site and reporting system is a Patient Safety Organization that collects data on errors associated with electronic health records.
Book/Report
Hospital Reporting Program: Annual Summary.
Portland, OR: Oregon Patient Safety Commission.
This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.
Audiovisual
2014 Serious Reportable Events in Massachusetts.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; June 2015.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest increase in serious reportable events recorded, from 753 the previous year to 821. This presentation also includes events from ambulatory surgery centers.
Audiovisual
Healthcare 411: medication safety toolkit.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Book/Report
A safer place for patients: learning to improve patient safety.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
Using data from approximately 974,000 patient safety incidents and near misses reported to the National Patient Safety Agency between 2004–2005, this report summarizes trends, improvements, and areas of weakness in incident reporting.
Book/Report
Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Press Release/Announcement
Patient Safety Improvement Corps: An AHRQ/VA partnership.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Web Resource > Multi-use Website
Patient & Worker Safety.
AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses' (AORN) patient safety initiative targeting the needs of perioperative registered nurses. It develops new guidelines related to patient safety issues (such as medication safety and prevention of retained surgical items) and helps health care professionals ensure that best practices are followed.