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United States of America
Search results for "State Governments and Agencies"
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- State Governments and Agencies
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Book/Report
Indiana Medical Error Reporting System: Final Report for 2014.
Whitson T, Garten B, Ordway GV. Indianapolis, IN: Indiana State Department of Health; 2015.
This annual report provides information on never events reported to the Indiana Medical Error Reporting System. The most common problems in the 114 incidents reported in 2014 were advanced pressure ulcers, retained foreign objects, and wrong-site surgery. Past reports are also available.
Web Resource > Government Resource
Betsy Lehman Center for Patient Safety and Medical Error Reduction.
Center for Health Information and Analysis.
The Betsy Lehman Center is an independent organization named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Book/Report
Legislative Report to the General Assembly: Adverse Event Reporting.
Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October 2016.
This annual publication provides data on adverse events reported to the Connecticut Department of Public Health. The most recent report discusses an analysis of the 456 incidents submitted in 2015, which represents a slight decrease. The most common adverse events reported were pressure ulcers and fall-related injuries or deaths. Past reports are also available.
Web Resource > Multi-use Website
Massachusetts Alliance for Communication and Resolution Following Medical Injury.
Beth Israel Deaconess Medical Center and Massachusetts Medical Society.
Communication-and-response programs emphasize early disclosure of adverse events and proactive attempts to resolve incidents. This Web site provides resources for a collaborative effort to teach hospitals about disclosing to patients who have experienced a medical error.
Web Resource > Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Children are often prescribed oral liquid medications due to difficulty swallowing tablets or capsules. This Web site provides resources for an initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead to medication errors.
Web Resource > Multi-use Website
Reducing Avoidable Readmissions Effectively (RARE) Campaign.
Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health.
This Web site hosts materials to help hospitals enhance discharge planning, medication management, patient and family engagement, care transition, and communication as elements of a state-wide collaborative to reduce readmissions. The program received a 2013 Eisenberg Award.
Book/Report
Maryland Hospital Patient Safety Program Annual Report: Fiscal Year 2014.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; March 2015.
This annual report summarizes never events in Maryland hospitals over the previous year. In 2014, reported hospital-acquired infections and readmissions decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including standardizing processes and engaging hospital and departmental leaders in safety initiatives.
Web Resource > Multi-use Website
Quality and Safety.
Florida Hospital Association.
This Web site offers information about quality improvement programs in Florida, including the Florida Surgical Care Initiative and the FHA Hospital Engagement Network.
Newspaper/Magazine Article
Oral medications inadvertently given via the intravenous route.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Newspaper/Magazine Article
Spotlight on electronic health record errors: errors related to the use of default values.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Web Resource > Government Resource
Sentinel Event Program.
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Web Resource > Multi-use Website
Patient Safety.
Minnesota Hospital Association.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Special or Theme Issue
Handoff Communication Tools.
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Web Resource > Multi-use Website
Ohio Patient Safety Institute (OPSI).
Ohio Hospital Association (OHA), 155 East Broad St. Floor 15, Columbus, OH 43215-3620.
The Ohio site outlines the structure of their organization and provides information on various initiatives, including brown bag luncheons for seniors to discuss their medications with a pharmacist, professional education programs, and a learning library.
Web Resource > Multi-use Website
Minnesota Alliance for Patient Safety (MAPS).
Minnesota Hospital and Healthcare Partnership.
The Minnesota Alliance for Patient Safety (MAPS) is a partnership among the Minnesota Hospital Association, Minnesota Medical Association, Minnesota Department of Health, and more than 50 other public-private health care organizations to improve patient safety. Site highlights include information on their "Patients as Partners" campaign.
Web Resource > Multi-use Website
Utah DoH Patient Safety Initiatives.
P.O. Box 1010, Salt Lake City, UT 84114-1010.
Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse events and implement interventions to reduce their incidence. This site provides access to an adverse drug event (ADE) reporting tool, state administrative rules related to safety, a national patient safety program funded by the Agency for Healthcare Research and Quality (AHRQ), and a complaints mechanism for consumers.
Web Resource > Multi-use Website
Washington Patient Safety Coalition.
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
This coalition supports a network of patient safety professionals to facilitate dialogue, promote initiatives on eliminating wrong-site surgery, and improve medication safety.
Web Resource > Multi-use Website
Texas Advocates for Patient Safety.
Franklin Foundation; Dallas, TX.
An advocacy site presenting the personal journey of one family in Texas who, after losing a parent to a medical error, launched a campaign in their state for change.
Web Resource > Multi-use Website
Patient Safety Authority.
333 Market Street, Lobby Level, Harrisburg, PA 17120.
The Patient Safety Authority is an independent state agency charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions. The site includes information on the mandatory statewide Pennsylvania Patient Safety Reporting System.
Web Resource > Multi-use Website
Maryland/DC Patient Safety Coalition.
Delmarva Foundation, 9240 Centreville Rd, Easton, MD.
The Maryland Patient Safety Center facilitates the study of unsafe practices and the implementation of practical improvements to prevent errors. The center is a collaboration of two organizations that have led safety/quality initiatives in Maryland: Maryland Hospital Association and Delmarva Foundation. The center is a nonregulatory and statewide effort.