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Medical Errors, Patient Safety and Adverse Events

Categories

Primary Listings

Sometimes called the list of Never Events, this report identifies 29 serious reportable events (SREs) considered preventable events. Examples: wrong surgery; deaths or serious injury associated with medication error, or in a low-risk pregnancy, or due to a fall, or from failure to follow up on test results, or associated with certain MRI incidents; Stage 3 or 4 pressure ulcers. Applies to hospitals, clinics, nursing homes and ambulatory surgery centers. Updated from 2006 edition; published by National Quality Forum

Healthgrades - Hospital Awards for Patient Safety Excellence, 2017

List of top 10% (460) hospitals, distinguished for their Medicare patient safety, using 2013 to 2015 data. List evaluates hospital patient safety incidents, such as leaving foreign objects behind during surgery, pressure ulcers [bedsores], accidental cuts during medical care; deep blood clots, collapsed lung pneumothorax, postoperative hip fracture, bloodstream infection and postop sepsis. Annual study released 2017 by Healthgrades

How good is hospital care in the US (Nov. 2010 pdf)

Study of adverse events experienced by Medicare patients in hospitals during October 2008. An estimated 13.5% experienced events; about 44% were judged by physicians to be preventable. Published by Office of Inspector General (OIG) in Nov. 2010

NQF 34 Safe Practices for Hospitals 2009 (pdf)

National Quality Forum's (NQF) consensus on 34 patient safety practices are summarized in this public document. Includes practices related to organizational culture; hand hygiene and preventing infection; information documentation, labeling, and communication; caregiver practices; discharge and medication reconciliation systems; more. Pub. March 2009, 12 pages.

When Things Go Wrong: Responding to Adverse Events (pdf)  Editor's Pick

How to communicate with patients about serious medical errors and adverse events. Includes elements of a hospital incident policy, sample script for communicating with patients, supporting the staff, support to families; and extensive bibliography. Prepared by the Harvard teaching hospitals; published by the Massachusetts Coalition for the Prevention of Medical Errors (macoalition.org), 42 pages, March 2006. Classic publication

Work Culture - Physicians and Nurses

Results of survey from July-August 2009 of doctors and nurses (about 16% response rate) pertaining to how they treat each other. Degrading comments were a common complaint. Unfortunately, the verbatim comments are no longer available. Published by American College of Physician Executives (acpe.org) Nov. 2009

Other Helpful Listings

National Practitioner Data Bank - Annual Report 2012 (pdf)

Data from the National Practitioner Data Bank show median malpractice payment amount in 2012 for an anesthesia related case was $240,000; for an IV or blood products related case, it was $169,000. Data are mixed up in Tables 25 and 26. Delay between incident and payment was typically 4 to 7 years. NPDB Report from 2012 is 78 pages

Sentinel Event Definitions

The Joint Commission (which accredits healthcare organizations, formerly JCAHO) defines Sentinel Events for hospitals and other health care settings

WHO Collaborating Centre: Nine Life-Saving Patient Safety Solutions

Short summaries and pdf action guides for 9 patient safety problems: Look-alike, sound-alike medication names; Patient identification; Communication during patient hand-overs; Performing correct procedure at correct body site; Concentrated Electrolyte solutions; Medication accuracy at transitions in care; Catheter and tubing mis-connections; Single use of injection devices, and Hand Hygiene to prevent health care-associated infections. From the World Health Organization (WHO) and Joint Commission / International, 2007

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