Book/Report 62
Congressional Testimony 3
Web Resource 57
Government Resource 46
Multi-use Website 16
Practice Guidelines 17
Administration Errors 24
Specific to High-Risk Drugs 12
Allied Health Services 1
Nurse Managers 20
Nurses 23
Department of Health and Human Services (HHS) 59
Agency for Healthcare Research and Quality (AHRQ) 42
Blind spots in the science of safety. Get Citation
Bosk CL, Pedersen KZ. Lancet. 2019;393:978-979.
Safety sciences offer methods to enhance processes and develop organizational culture. This commentary elucidates on the limitations of applying the principles of a science of safety to health care. These weaknesses involve the tension between prospective and retrospective preventability, failure to consider human factors, and the need to understand how context affects care delivery.
Organizing Patient Safety: Failsafe Fantasies and Pragmatic Practices.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.
Operating room hazards and approaches to improve patient safety. Get Citation
Wahr JA. UpToDate. March 26, 2019.
The operating room is a high-risk environment influenced by culture, teamwork, and task complexity. This review provides an overview of patient safety challenges in the operating room and highlights key approaches for improvement such as system engineering, collaboration, and checklists.
Betsy Lehman Center for Patient Safety.
Center for Health Information and Analysis.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency 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.
Patient Safety 2015: Final Technical Report.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. Get Citation
Gerstein WH, Ledford J, Cooper J, et al. Am J Med Qual. 2016;31:162-168.
This study describes the implementation of a systems-focused morbidity and mortality conference at a Veterans Health Administration medical center designed to augment patient care and promote interdisciplinary teamwork and transparency, while addressing residency requirements. The intervention demonstrated lasting improvements in systems issues, consistent with prior data using this learning format.
Creating a fellowship curriculum in patient safety and quality. Get Citation
Abookire SA, Gandhi TK, Kachalia A, et al. Am J Med Qual. 2016;31:27-30.
This commentary describes the development of a quality and safety clinical fellowship curriculum which focused on identifying core competencies and then incorporating training for these principles in an operational setting. A companion article explores the implementation of this curriculum at hospitals affiliated with Harvard Medical School.
Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives. Get Citation
Richter JP, McAlearney AS, Pennell ML. Am J Med Qual. 2015;30:550-558.
Voluntary error reporting is a critical mechanism for identifying patient safety issues in an organization. However, the process is dependent on a culture of safety that enables providers to report mistakes and near misses. This study used the AHRQ Hospital Survey on Patient Safety Culture comparative database to test organizational factors that may predict more robust error reporting. Error feedback and organizational learning were most associated with perceptions of frequent error reporting, supporting the importance of hospitals demonstrating that reports are seriously considered and acted upon. Some manager respondents did not seem to recognize the significance of perceived management support in enabling error reporting. A prior AHRQ WebM&M perspective discussed the establishment of a safety culture in health care organizations.
The role of failure mode and effects analysis in health care.
Fibuch E, Ahmed A. Physician Exec. Jul-Aug 2014;40:28-32.
Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.
Maryland Hospital Patient Safety Program Annual Report: Fiscal Year 2017.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Researchers' roles in patient safety improvement. Get Citation
Pietikäinen E, Reiman T, Heikkilä J, Macchi L. J Patient Saf. 2016;12:25-33.
Through a self-reflective narrative, this commentary offers insights into the authors' experience investigating, developing, and implementing a patient safety improvement project. The researchers suggest that this analysis helped improve understanding of key team member roles and areas to enhance collaboration.
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement? Get Citation
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
TalkingQuality.
Agency for Healthcare Research and Quality.
This Web site provides tools to help organizations create and distribute quality of care reports to consumers.
Overview of progress on patient safety. Get Citation
Pronovost PJ, Holzmueller CG, Ennen CS, Fox HE. Am J Obstet Gynecol. 2011;204:5-10.
The first in a new patient safety series, this article reviews efforts to improve safety in obstetrics and gynecology, provides a framework for research, and offers suggestions to enhance safety in the specialty.
How hospital design saves lives.
Blum A. Business Week. August 15, 2006.
This article discusses how hospital design, including standardized operating rooms, better ventilation systems, and green design can improve patient safety and decrease costs.
New standards for hospitals call for patients to get private rooms.
Landro L. The Wall Street Journal. March 22, 2006:A1.
This article reports on design guidelines that will require newly constructed hospitals to have only private rooms. Single-patient rooms may help reduce infection rates, improve recovery time, and enhance patient safety.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC). Get Citation
Gates PJ, Baysari MT, Mumford V, Raban MZ, Westbrook JI. Drug Saf. 2019 Apr 23; [Epub ahead of print].
Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.