Quality & Patient Safety

Quality & Patient Safety Articles by Topic: Adverse Events

The 'Wild West' of patient safety measures and public reporting

  • Patient Safety Monitor, Issue 2, February 1, 2014

    Look at any hospital ranking system and you’ll see the same headlines: “Best hospitals...

Updated Hospital Safety Scores show slow improvement

  • Patient Safety Monitor, Issue 2, February 1, 2014

    More than 2,500 general hospitals in the United States received Hospital Safety Scores, and...

Patients might gain power to report on medical errors

  • Patient Safety Monitor Insider, Issue 39, September 25, 2012

    The Obama administration has proposed a consumer reporting system that will allow patients to...

New death from superbug at NIH facility

  • Patient Safety Monitor Insider, Issue 38, September 18, 2012

    A seventh patient has died due to a drug-resistant strain of the bacterium Klebsiella pneumoniae...

Despite studies on the "weekend effect," results are inconclusive

  • Patient Safety Monitor Insider, Issue 34, August 21, 2012

    Although two recent studies support the argument for the existence of a “weekend...

Hospitals fail to report adverse events, according to OIG

  • Patient Safety Monitor Insider, Issue 30, July 24, 2012

    An estimated 60% of adverse events occurred at hospitals in states with reporting systems, yet only...

$825,000 in fines for California hospitals

  • Patient Safety Monitor Insider, Issue 23, June 6, 2012

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Death of organ donor during surgery raises patient safety questions

  • Patient Safety Monitor Insider, Issue 15, April 11, 2012

    The widow of a man who died while donating a part of his liver to his brother-in-law plans to file...

Editor’s pick: Adverse Events Reporting: Do you comply with OIG recommendations?

  • Patient Safety Monitor Insider, Issue 12, March 21, 2012

    The Office of Inspector General (OIG) has looked at CMS and found its system of hospital oversight...

EMR implementations improve quality measures for hospitals

  • Patient Safety Monitor Insider, Issue 10, March 7, 2012

    Hospitals that have implemented advanced electronic medical record (EMR) systems have seen...

New York hospital faces vast quantity of lawsuits

  • Patient Safety Monitor Insider, Issue 10, March 7, 2012

    More than 100 patients or families of patients have filed lawsuits against Brookdale University...

Using death rates to evaluate hospital quality faulted, study finds

  • Patient Safety Monitor Insider, Issue 2, January 11, 2012

    A new study has researchers at Yale School of Medicine questioning whether death rates in hospitals...

Investigation by HHS finds many unreported errors

  • Patient Safety Monitor Insider, Issue 2, January 11, 2012

    According to a report from the inspector general of the Department of Health and Human Services...

Family of patient settles with MGH over alarm sentinel event

  • Patient Safety Monitor Insider, Issue 48, November 30, 2011

    The family of a patient who died after nurses failed to respond to alarms on his cardiac monitor...

Family of girl whose limbs were amputated after long ED wait reach settlement

  • Patient Safety Monitor Insider, Issue 44, November 2, 2011

    One of the largest settlements of its kind in California was reached October 28. Methodist Hospital...

Public Citizen calls for investigation into patient deaths

  • Patient Safety Monitor Insider, Issue 43, October 26, 2011

    Public Citizen, a nonprofit organization that helps advocate for individual rights, is calling for...

IHI releases new edition of Managing Serious Events report

  • Patient Safety Monitor Insider, Issue 41, October 19, 2011

    The Institute of Healthcare Improvement (IHI) has released a second edition of its Respectful...

ED physicians sue WA state

  • Patient Safety Monitor Insider, Issue 40, October 5, 2011

    Emergency physicians in the state of Washington have filed a lawsuit against a state plan to...

Medication error occurred during nurses’ strike

  • Patient Safety Monitor Insider, Issue 39, September 28, 2011

    A patient death at Alta Bates Summit Medical Center in Oakland, CA, that has been connected with a...

Inexpensive infection control saves millions of lives, billions of dollars

  • Patient Safety Monitor Insider, Issue 37, September 14, 2011

    A new study by University of North Carolina (UNC) at Chapel Hill found that adopting inexpensive...

Temp ED nurses a safety threat to patients, study shows

  • Patient Safety Monitor Insider, Issue 35, August 31, 2011

    Temporary emergency department (ED) nurses who are unfamiliar with their surroundings may...

Heart attack patients cared for quicker

  • Patient Safety Monitor Insider, Issue 34, August 24, 2011

    Almost all major heart attack patients are being treated within 90 minutes of arrival according to...

Nurses demand better staffing levels, citing patient safety

  • Patient Safety Monitor Insider, Issue 33, August 17, 2011

    The Pennsylvania state Department of Health’s recent investigation of Carlisle (PA) Regional...

CMS expands Hospital Compare data

  • Patient Safety Monitor Insider, Issue 32, August 10, 2011

    Federal health officials have announced that they have expanded the HospitalCompare website, making...

American College of Surgeons announce National Surgical Quality Improvement Program

  • Patient Safety Monitor Insider, Issue 31, August 3, 2011

    The American College of Surgeons (ACS) announced its goal to enlist at least 1,000 hospitals into...

In Ireland, law would require admission of medical mistakes

  • Patient Safety Monitor Insider, Issue 3, August 3, 2011

    In an effort to ensure more reporting of adverse events, Minister for Health James Reilly is...

Leape calls medical resident hours rule an ?abuse of trust?

  • Patient Safety Monitor Insider, Issue 28, July 13, 2011

    Editor’s note:  New rules on medical residents' hours issued by The Accreditation...

Oregon finds pharmacists reluctant to use reporting system

  • Patient Safety Monitor Insider, Issue 27, July 6, 2011

    In2008, the Oregon Patient Safety Commission implemented an adverse event reporting system that...

Not enough research to substantiate assumption that July brings higher mortality rates

  • Patient Safety Monitor Insider, Issue 27, July 6, 2011

    Because a new class of medical school graduates begin their  residencies in July, the month...

Up to $500 million in Affordable Care Act funding will help health providers improve care

  • Patient Safety Monitor Insider, Issue 26, June 29, 2011

    Up to $500 million will be awarded by the Centers for Medicare & Medicaid Services (CMS...

Double hest scans risking patient safety

  • Patient Safety Monitor Insider, Issue 25, June 22, 2011

    Many hospitals are performing a type of chest scan that give patients too much radiation at a time...

Long ED wait times tied to mortality risk

  • Patient Safety Monitor Insider, Issue 23, June 8, 2011

    A new study published in the June 2011 issue of British Medical Journal found that patient...

Large academic health systems not necessarily better at HAI prevention

  • Patient Safety Monitor Insider, Issue 23, June 8, 2011

    Consumer Reports recently studied 61 health systems with at least five hospitals that publicly...

Study finds e-prescribing system raises certain medication errors

  • Patient Safety Monitor Insider, Issue 22, June 1, 2011

    A new study in the Journal of General Internal Medicine found that although e-prescribing systems...

$4.7 million award for surgeon against Cedars Sinai upheld

  • Patient Safety Monitor Insider, Issue 22, June 1, 2011

    A California Court of Appeals in Los Angeles upheld a $4.7 million arbitration award to a skull...

Cardiac monitoring of wrong patients resulting in death

  • Patient Safety Monitor Insider, Issue 21, May 25, 2011

    The ECRI Institute Patient Safety Organization (PSO) has received reports of cardiac monitoring of...

Higher mortality rates for patients admitted on weekends

  • Patient Safety Monitor Insider, Issue 20, May 18, 2011

    A new study in the May issue of Archives of Surgery concludes that patients admitted on weekends...

New triage, physician-nurse huddles, discharge time outs new strategies to stop patient harm in ER

  • Patient Safety Monitor Insider, Issue 19, May 11, 2011

    Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University, is...

CMS finds multiple patient safety deficiencies at Parkland Hospitals

  • Patient Safety Monitor Insider, Issue 18, May 4, 2011

    The Centers for Medicare & Medicaid Services (CMS) found multiple patient safety deficiencies...

Post-surgical method helps to reduce surgical site infection

  • Patient Safety Monitor Insider, Issue 17, April 27, 2011

    The simple bedside technique of gently probing a surgical incision to clean it has been shown to...

Heavy drinkers suffer more deadly infections

  • Patient Safety Monitor Insider, Issue 16, April 20, 2011

    Patients with alcohol use disorders might be more likely to die from healthcare-associated...

HHS invests $1 billion toward patient safety initiative

  • Patient Safety Monitor Insider, Issue 15, April 13, 2011

    Health and Human Services Secretary Kathleen Sebelius, and Centers for Medicare & Medicaid...

Hands-free faucets much more likely carry Legionella than traditional faucets

  • Patient Safety Monitor Insider, Issue 14, April 6, 2011

    Because hands-free faucets are touched less often, it is widely assumed such faucets carry fewer...

Tainted alcohol wipes cause infections at Colorado hospital

  • Patient Safety Monitor Insider, Issue 10, March 9, 2011

    Staff at the Children's Hospital in Aurora, CO, became alarmed last fall when some young patients...

CDC urges hospitals to adopt CLABSI prevention strategies

  • Patient Safety Monitor Insider, Issue 10, March 9, 2011

    The Centers for Disease Control and Prevention (CDC) have issued a press release and media advisory...

Radiation risk rises to top of patient safety concerns

  • Patient Safety Monitor Insider, Issue 8, February 23, 2011

    A woman who receives one abdominal-pelvic CT scan has a one in 250 chance of getting cancer. This...

Tufts Medical Center nurses hold candlelight vigil for patient safety

  • Patient Safety Monitor Insider, Issue 7, February 16, 2011

    Nurses at Tufts Medical Center in Boston are holding a candlelight vigil on February 15, 2011 for...

VA hospital halts all surgeries

  • Patient Safety Monitor Insider, Issue 6, February 9, 2011

    After an inspection that showed possible contamination of surgical equipment, the John Cochran...

Infection checklist proven to save lives

  • Patient Safety Monitor Insider, Issue 5, February 2, 2011

    The checklist Peter Pronovost, MD, professor of anesthesiology and critical care medicine at Johns...

Is patient care lacking after a fall?

  • Patient Safety Monitor Insider, Issue 5, February 2, 2011

    A new report published in the January 28, 2011 issue of British Medical Journal has found that...

New GE tool estimates cost of medical errors

  • Patient Safety Monitor Insider, Issue 2, January 12, 2011

    Risk managers, financial officers, and patient safety directors could likely spend countless hours...

C. diff in children on the rise

  • Patient Safety Monitor Insider, Issue 1, January 5, 2011

    Clostridium difficile (C. diff) is on the rise in U.S. children, reports the Los Angeles Times.

IHI white paper advises how to handle serious adverse events

  • Patient Safety Monitor Insider, Issue 1, January 5, 2011

    The Institute for Healthcare Improvement (IHI) has released a new free white paper on managing...

Drug shortages affecting patient care

  • Patient Safety Monitor Insider, Issue 52, December 29, 2010

    Some medications are in short supply at hospitals across the nation, reports ABC News.

Different methods to determine mortality rate produce vastly different results

  • Patient Safety Monitor Insider, Issue 52, December 29, 2010

    Whether or not a hospital gives quality care is often measured by mortality rate, but different...

After mother’s battle, CA hospital infection rates will go public

  • Patient Safety Monitor Insider, Issue 51, December 22, 2010

    A new California state law will mandate the reporting of line infections, methicillin-resistant...

Report finds Hospital Compare website leaves out sickest patients

  • Patient Safety Monitor Insider, Issue 49, December 8, 2010

    Quality rankings on The Centers for Medicare & Medicaid Services' (CMS) consumer website...

One in seven Medicare patients harmed from medical care

  • Patient Safety Monitor Insider, Issue 46, November 17, 2010

    A new government study has found that approximately 134,000 out of 1 million discharged Medicare...

FDA steps in on CT radiation overdoses

  • Patient Safety Monitor Insider, Issue 45, November 10, 2010

    The U.S. Food and Drug Administration (FDA), after investigating reports concerning computed...

After deaths, hospital launches ’zero errors’ initiative

  • Patient Safety Monitor Insider, Issue 44, November 3, 2010

    After two children died as a result of medication errors, Seattle Children's Hospital has launched...

Hospital cuts C. diff rate by 40%

  • Patient Safety Monitor Insider, Issue 44, November 3, 2010

    Integris Baptist Medical Center in Oklahoma City, OK, cut its Clostridium difficile (C. diff) rate...

Study finds surgical errors persist despite initiatives

  • Patient Safety Monitor Insider, Issue 42, October 20, 2010

    A study in the October issue of Archives of Surgery found that despite guidelines such as The Joint...

GE trialing ’Safe Patient Room’ technology to increase patient safety, cut errors

  • Patient Safety Monitor Insider, Issue 40, October 6, 2010

    The Institutional Review Board at Bassett Medical Center in Cooperstown, NY, has given GE...

Joint Commission updates blood transfusion requirements

  • Patient Safety Monitor Insider, Issue 39, September 29, 2010

    In the latest issue of The Joint Commission Online newsletter, The Joint Commission announced that...

Blue Cross Blue Shield announces no reimbursement for ’never events’

  • Patient Safety Monitor Insider, Issue 38, September 22, 2010

    The Blue Cross and Blue Shield Association announced that it has established a companywide payment...

Tubing misconnections come to the forefront

  • Patient Safety Monitor Insider, Issue 35, September 1, 2010

    Since 1996, many experts and standards groups have called for medical tubing regulation to prevent...

Leapfrog Group report says without proper monitoring, HIT could negatively affect patients

  • Patient Safety Monitor, Issue 9, September 1, 2010

    A new report released by The Leapfrog Group shows that computer physician order entry (CPOE...

From the Patient Safety Monitor Blog: Some medical students already taking patient safety courses

  • Patient Safety Monitor Insider, Issue 31, August 4, 2010

    Students at medical schools across the country are being given the opportunity to take elective...

Leapfrog report shows CPOEs can miss 30% of potentially fatal medication orders

  • Patient Safety Monitor Insider, Issue 27, July 7, 2010

    The Leapfrog Group released the results of a study that shows through web-based simulation that...

Briefings on Patient Safety July 2010

  • Patient Safety Monitor, Issue 7, July 1, 2010

    The July issue contains the following stories: Maryland program provides road map for...

Maryland program provides road map for reducing patient falls

  • Patient Safety Monitor, Issue 7, July 1, 2010

    If your hospital is lucky enough to be within the borders of the state of Maryland, you can...

Safety in the surgical environment

  • Patient Safety Monitor, Issue 7, July 1, 2010

    Editor’s note: The following column explores patient safety from the perspective of a...

PA Patient Safety Authority data show disruptive behavior can negatively affect patient care

  • Patient Safety Monitor Insider, Issue 24, June 16, 2010

    The Pennsylvania Patient Safety Authority (PPSA) has collected 177 reports of disruptive behavior...

AHRQ releases software to help hospitals analyze and publicize quality data

  • Patient Safety Monitor Insider, Issue 23, June 9, 2010

    Last Friday the Agency for Healthcare Research and Quality (AHRQ) announced it had created a new...

CA Children’s Hospital finds reduction in mortality with CPOE system

  • Patient Safety Monitor Insider, Issue 18, May 5, 2010

    Much debate has been had over whether computer-physician order entry (CPOE) systems have helped to...

From the Patient Safety Monitor Blog: Hospital culture report shows gains, areas for improvement

  • Patient Safety Monitor Insider, Issue 18, May 5, 2010

    The Agency for Healthcare Research and Quality (AHRQ) released a snapshot of the nation’s...

Briefings on Patient Safety May 2010

  • Patient Safety Monitor, Issue 5, May 1, 2010

    Inside: Report says medical students need increased training on patient safety Quilt...

Report says medical students need increased training on patient safety

  • Patient Safety Monitor, Issue 5, May 1, 2010

    Today’s medical students are not learning enough about patient safety, the importance of...

Good Catch program at Texas organization encourages near-miss reporting

  • Patient Safety Monitor, Issue 5, May 1, 2010

    Staff members are often trained to report a potential medical error, or near-miss event. However...

BMJ analysis: Mortality rates a poor measure of quality

  • Patient Safety Monitor Insider, Issue 17, April 28, 2010

    A new analysis from the British Medical Journal says that using mortality rates as a measure of...

From the Patient Safety Monitor Blog: HealthGrades releases 7th annual patient safety study

  • Patient Safety Monitor Insider, Issue 14, April 7, 2010

    HealthGrades has released the results of its 7th annual “Patient Safety in American...

New Jersey releases report of adverse events from 2008; falls are most reported

  • Patient Safety Monitor Insider, Issue 13, March 31, 2010

    The New Jersey Department of Health and Senior Services released a document earlier this week...

Heart and stroke patients may be victims of fewer medication errors with use of new protocol

  • Patient Safety Monitor Insider, Issue 12, March 24, 2010

    By following an eight-step protocol, caregivers working with heart and stroke patients could...

California Department of Health works with hospitals to prevent medical errors

  • Patient Safety Monitor Insider, Issue 11, March 17, 2010

    A 2007 law requiring that California hospitals report on 28 "never events" has helped...

More hospitals considering 'care of the caregiver' after medical error

  • Patient Safety Monitor Insider, Issue 11, March 17, 2010

    Hospitals are more often considering their employed caregiver's well-being after a medical error...

Briefings on Patient Safety March 2010

  • Patient Safety Monitor, Issue 3, March 1, 2010

    This issue contains articles about medical interpreter certification, patient safety awareness...

Certification defines qualified medical interpreters, keeps patients safe

  • Patient Safety Monitor, Issue 3, March 1, 2010

    One of the most vital parts of providing adequate healthcare is the exchange of information between...

Patient safety Q&A

  • Patient Safety Monitor, Issue 3, March 1, 2010

    Q: How should our organization meet compliance with educating patients and their families on...

Study: Sepsis, pneumonia responsible for the HAIs that killed 48,000 patients

  • Patient Safety Monitor Insider, Issue 8, February 24, 2010

    According to a study in the most recent issue of the Archives of Internal Medicine, sepsis and...

Patient characteristics, type of procedure may influence chance of "never event" occurring after surgery

  • Patient Safety Monitor Insider, Issue 7, February 17, 2010

    A study published in the February 2010 Archives of Surgery shows that the occurrence of...

Why don’t most physicians apologize for making mistakes?

  • Patient Safety Monitor Insider, Issue 5, February 3, 2010

    Even though much progress has been made since the first studies showing that physicians apologizing...

From the Patient Safety Monitor Blog: Joint Commission issues latest Sentinel Event Alert on preventing maternal death

  • Patient Safety Monitor Insider, Issue 4, January 27, 2010

    The Joint Commission issued its latest Sentinel Event Alert on Tuesday about preventing maternal...

HRET releases guide to help hospital leaders prevent readmissions

  • Patient Safety Monitor Insider, Issue 4, January 27, 2010

    The Health Research and Educational Trust, an affiliate of the American Hospital Association...

From the Patient Safety Monitor Blog: Patient safety group asks congress to include device identification system in health reform bill

  • Patient Safety Monitor Insider, Issue 3, January 20, 2010

    Members of the Advancing Patient Safety Coalition (APSC) wrote a letter to congressional leaders...

Using root cause analysis to improve patient safety

  • Patient Safety Monitor Insider, Issue 3, January 20, 2010

    A recent post written by Bob Wachter, MD, on the widely popular KevinMD blog, talks about how his...

From the Patient Safety Monitor Blog: OIG says adverse event reporting systems vary by state

  • Patient Safety Monitor Insider, Issue 2, January 13, 2010

    The Office of Inspector General released a memorandum last week saying that there is no...

California hospitals report an increase in adverse events

  • Patient Safety Monitor Insider, Issue 2, January 13, 2010

    Hospitals in California reported 1,583 serious preventable events occurring for the fiscal year...

Study: Inpatients often unsure of which medications they are taking

  • Patient Safety Monitor Insider, Issue 51, December 23, 2009

    A study published in the Journal of Hospital Medicine found that hospitalized patients are often...

Patient safety grants available for interested healthcare organizations

  • Patient Safety Monitor Insider, Issue 50, December 16, 2009

    There is $25 million available in grants from the federal government for improving patient safety...

VHA examination of surgical errors find poor communication most common culprit

  • Patient Safety Monitor Insider, Issue 50, December 16, 2009

    Poor communication was the most common cause of wrong-site, -side, and -person, surgeries at the...

AHRQ offers ten tips for keeping patients safe

  • Patient Safety Monitor Insider, Issue 50, December 16, 2009

    For those hospitals looking for a concise list of actions to take to prevent adverse events and...

INQRI blog hosts two-week series in observance of "To Err is Human" anniversary

  • Patient Safety Monitor Insider, Issue 49, December 9, 2009

    The Interdisciplinary Nursing Quality Research Initiative (INQRI) blog, a resource for nursing and...

In the ten years since "To Err is Human," has patient safety been improved?

  • Patient Safety Monitor Insider, Issue 48, December 2, 2009

    November 2009 marked the ten year anniversary since the Institute of Medicine (IOM) released its...

Study: Burnout, depression affect likelihood of American surgeons committing errors

  • Patient Safety Monitor Insider, Issue 47, November 25, 2009

    Some surgeons are likely to commit medical errors if they are suffering from burnout and...

Connecticut hospitals reporting fewer adverse events; many go uninvestigated

  • Patient Safety Monitor Insider, Issue 46, November 18, 2009

    Members of the public in the state of Connecticut are being increasingly kept in the dark about...

Introducing Patient Safety Monitor!

  • Patient Safety Monitor Insider, Issue 46, November 18, 2009

    HCPro is proud to announce its latest patient safety product: Patient Safety Monitor.

Survey: Patients think healthcare is better if they are told about errors

  • Patient Safety Monitor Insider, Issue 45, November 11, 2009

    A study published in the November 9 Archives of Internal Medicine reveals that hospital staff...

Diagnosis errors: No easy fix

  • Patient Safety Monitor Insider, Issue 45, November 11, 2009

    Physicians are responsible for one of the most complicated and important decisions in...

Cedars-Sinai offers to pay patients’ further medical costs for overexposure to radiation

  • Patient Safety Monitor Insider, Issue 45, November 11, 2009

    After admitting last month it delivered radiation via CT scans to patients at eight times the...

Tamiflu ® shortage sparks dosing confusion at some facilities

  • Patient Safety Monitor Insider, Issue 44, November 4, 2009

    The Pennsylvania Patient Safety Authority has issued an advisory regarding the use of Tamiflu in...

RI hospital commits fifth wrong-site surgery since January 2007

  • Patient Safety Monitor Insider, Issue 44, November 4, 2009

    Staff members at Rhode Island Hospital in Providence, RI, have committed the facility's fifth...

Medical Liability and Patient Safety Reform Committee meets for first time

  • Patient Safety Monitor Insider, Issue 43, October 28, 2009

    The initial meeting of the Subcommittee on Patient Safety and Medical Liability Reform...

Washington State Department of Health to investigate lack of reported medical errors

  • Patient Safety Monitor Insider, Issue 41, October 14, 2009

    Washington is one of the only states in the nation to require mandatory reporting of medical...

Los Angeles hospital admits to radiation errors

  • Patient Safety Monitor Insider, Issue 41, October 14, 2009

    Cedars-Sinai Medical Center in Los Angeles, CA, has found that it accidentally administered...

The sleep factor: Do less tired physicians deliver safer care?

  • Patient Safety Monitor Insider, Issue 40, October 7, 2009

    The debate on whether reducing the number of hours that graduate medical students can work...

Could a federal patient safety agency offer a solution to rising number of errors?

  • Patient Safety Monitor, Issue 10, October 1, 2009

    In the decade that has passed since the 1999 release of the Institute of Medicine’s To Err is...

Study: Medical errors may not increase during July, contrary to popular belief

  • Patient Safety Monitor Insider, Issue 39, September 30, 2009

    A study published in the September 2009 Journal of the American College of Surgeons has concluded...

Apologetic physicians earn higher rankings, but still may be sued

  • Patient Safety Monitor Insider, Issue 38, September 23, 2009

    A recent study in the Journal of General Internal Medicine found that physicians who were...

Electronic alerts may prevent substantial number of prescribing errors

  • Patient Safety Monitor Insider, Issue 37, September 16, 2009

    Electronic alerts were found to have had a significant impact on the number of potential...

JAMA commentary: Patient safety priority list would help improve outcomes

  • Patient Safety Monitor Insider, Issue 35, September 2, 2009

    A recent commentary in the Journal of the American Medical Association calls for a list of patient...

New Jersey law makes hospital errors more transparent to public

  • Patient Safety Monitor Insider, Issue 35, September 2, 2009

    New Jersey joins a list of states that by law requires hospitals to provide information about...

The patient’s role in error reporting

  • Patient Safety Monitor, Issue 9, September 1, 2009

    In the past ten years, a fair amount of headway has been made in refining error reporting systems...

Briefings on Patient Safety, September 2009

  • Patient Safety Monitor, Issue 9, September 1, 2009

    This issue contains stories that discuss a new consumer reporting system developed by the Agency...

Will full disclosure actually lower medical errors?

  • Patient Safety Monitor Insider, Issue 4, August 26, 2009

    Traditionally, the healthcare system has taken an approach to medical errors that involves secrecy...

KFF survey finds EDs seeing more uninsured patients during recession, capacity strained

  • Patient Safety Monitor Insider, Issue 32, August 12, 2009

    A new survey from the Kaiser Family Foundation released last week shows that emergency departments...

Consumer activist group's list of ten patient safety reforms could save 85,000 lives

  • Patient Safety Monitor Insider, Issue 32, August 12, 2009

    In a new report titled "Back to Basics," the consumer activist group Public Citizen has...

Ambulatory chronic disease patients suffer preventable medical errors

  • Patient Safety Monitor Insider, Issue 30, July 29, 2009

    An article in the July Joint Commission Journal on Quality and Patient Safety highlights the gaps...

The Institute for Safe Medication Practices reports potential problems with pain pump

  • Patient Safety Monitor Insider, Issue 30, July 29, 2009

    The Institute for Safe Medication Practices (ISMP) warned of potential misuse of pain release balls...

New York State releases data for HAI rates at specific hospitals

  • Patient Safety Monitor Insider, Issue 4, July 8, 2009

    Stemming from the mandate of a 2005 law, the New York State Department of Health released a report...

New infection control product monitors hand hygiene

  • Patient Safety Monitor Insider, Issue 24, June 17, 2009

    Performing hand hygiene adequately and often is something that many healthcare facilities are...

Maryland hospital fined for failing to report errors

  • Patient Safety Monitor Insider, Issue 24, June 17, 2009

    For the first time since the state began requiring hospitals to report serious medical errors five...

Leaders in healthcare struggle with decision of how to reduce costs

  • Patient Safety Monitor Insider, Issue 23, June 10, 2009

    Although U.S. leaders in industry and politics agree that the healthcare system needs a complete...

Washington DC area experiencing extreme emergency department overcrowding

  • Patient Safety Monitor Insider, Issue 22, June 3, 2009

    In what healthcare analysts believe to be representative of the nation as a whole, hospitals are...

Study examines incidence of inconsistent communication present with CPOE

  • Patient Safety Monitor Insider, Issue 22, June 3, 2009

    Computer Physician Order Entry (CPOE) has been thought to be one method to reduce the number of...

Pilot project to track adverse events related to blood transfusions

  • Patient Safety Monitor Insider, Issue 19, May 13, 2009

    Nine hospitals began taking part in a pilot program last week to track and analyze adverse events...

AHA supports 80-hour standard for residents, offers suggestions

  • Patient Safety Monitor Insider, Issue 16, April 22, 2009

    The American Hospital Association (AHA) voiced support of the American Council for Graduate Medical...

Malaysian private hospitals required to implement safe treatment plan

  • Patient Safety Monitor: Global Edition, Issue 7, April 14, 2009

    Beginning this year, Malaysia’s Health Ministry will implement the "Incident Reporting...

Jordan hospitals pledge to implement HCAC National Quality and Patient Safety Goals

  • Patient Safety Monitor: Global Edition, Issue 7, April 14, 2009

    At a recent press conference held at Jordan’s Health Care Accreditation Council (HCAC...

Ireland: Small hospitals to be reviewed after poor report

  • Patient Safety Monitor: Global Edition, Issue 7, April 14, 2009

    After Ennis General Hospital received a poor report about their quality and patient safety services...

Ontario: Private medical clinics soon to be regulated

  • Patient Safety Monitor: Global Edition, Issue 7, April 14, 2009

    After a two-year investigation conducted by The Star of the cosmetic surgery industry and its lack...

New tuberculosis drug tested in Brazil passes early stages of process

  • Patient Safety Monitor: Global Edition, Issue 7, April 14, 2009

    A new antibiotic aimed at shortening the time to cure tuberculosis (TB) has passed a key phase...

HealthGrades releases sixth annual patient safety study results

  • Patient Safety Monitor Insider, Issue 14, April 8, 2009

    The sixth annual HealthGrades Patient Safety in American Hospitals Study was released on April 7...

Proposed patient safety group looks to aviation model to improve processes

  • Patient Safety Monitor Insider, Issue 14, April 8, 2009

    A paper published in the most recent issue of Health Affairshighlights some of the areas in which...

UK: Patients Association urges NHS to make reporting mandatory

  • Patient Safety Monitor: Global Edition, Issue 6, March 31, 2009

    After a highly criticized report of one Stafford hospital led the Healthcare Commission to brand...

Hong Kong Hospital Authority fighting allegations of faulty drugs

  • Patient Safety Monitor: Global Edition, Issue 6, March 31, 2009

    Police have been called in to help investigate the Hospital Authority's most recent allegation of...

WHO surgical safety checklist to be introduced in Trinidad

  • Patient Safety Monitor: Global Edition, Issue 6, March 31, 2009

    Trinidad's Health Ministry will be taking a step toward improving patient safety by introducing the...

Wales: Mistakes or errors in hospitals claim the lives of 30 patients during six month span

  • Patient Safety Monitor: Global Edition, Issue 6, March 17, 2009

    The National Patient Safety Agency (NPSA) revealed new figures stating that during a recent six...

UK: NPSA releases list of eight mistakes that must never be committed by NHS

  • Patient Safety Monitor: Global Edition, Issue 6, March 17, 2009

    The National Patient Safety Agency (NPSA) has composed a list of eight errors that National Health...

Lasik eye surgery poses safety concern in Japan

  • Patient Safety Monitor: Global Edition, Issue 6, March 17, 2009

    Public concern is rising after a Tokyo eye clinic revealed that 67 patients have suffered from...

Canada: Healthcare delivery changing with technology

  • Patient Safety Monitor: Global Edition, Issue 6, March 17, 2009

    The way in which patients and healthcare providers communicate will be revolutionized by the use of...

NYC hospitals faulted for inadequately reporting near misses and adverse events

  • Patient Safety Monitor Insider, Issue 10, March 11, 2009

    A recent report by the New York City (NYC) comptroller found that hospitals in NYC report...

Press Ganey releases culture of safety report; finds assessing blame for errors is often why errors occur

  • Patient Safety Monitor Insider, Issue 10, March 11, 2009

    Press Ganey, a consulting firm that works with 40% of the nation's hospitals to help improve...

UK: A quarter of NHS acute trusts fail to use new WHO surgery checklists

  • Patient Safety Monitor: Global Edition, Issue 5, March 3, 2009

    Six months after the launch of the World Health Organization’s (WHO) new pre-operative...

Australia: Ventracor device banned after three deaths worldwide

  • Patient Safety Monitor: Global Edition, Issue 5, March 3, 2009

    Ventracor's VentrAssist, an implant used to treat heart failure, will be banned worldwide after the...

Irish Medicine Board requests wait between low dose-aspirin and ibuprofen use

  • Patient Safety Monitor: Global Edition, Issue 5, March 3, 2009

    The Irish Medicines Board (IMB) has asked that manufactures of the drug ibuprofen update its...

Psoriasis drug under investigation by FDA

  • Patient Safety Monitor: Global Edition, Issue 5, March 3, 2009

    The U.S. Food and Drug Administration (FDA) issued a public health advisory for patients using the...

UK: Patient safety organization urges review after widespread laxative use errors

  • Patient Safety Staff Challenge: Global Edition, Issue 5, March 3, 2009

    The National Patient Safety Foundation (NPSF) has urged all National Health System (NHS) and...

UK: Lack of new X-ray facilities putting patients; lives at risk

  • Patient Safety Monitor: Global Edition, Issue 4, February 17, 2009

    Britain's most senior radiology specialist announced that unnecessary deaths are occurring because...

Ireland's new patient safety plan offers protection to whistleblowers

  • Patient Safety Monitor: Global Edition, Issue 4, February 17, 2009

    In Ireland, a cabinet-proposed plan will protect healthcare staff members wishing to report on...

Australia: Quality of care affected as hospitals hit financial bottom

  • Patient Safety Monitor: Global Edition, Issue 4, February 17, 2009

    As New South Wales (NSW) public hospitals report their worst financial results on record for the...

Educating patients prior to discharge can lower costs, readmission rates

  • Patient Safety Monitor Insider, Issue 5, February 4, 2009

    Patients who have been educated about how to continue their care once they are discharged from the...

Detroit hospital sued for refusal to release records after patient death

  • Patient Safety Monitor Insider, Issue 5, February 4, 2009

    Detroit Medical Center (DMC) is being sued for failing to release peer review records and other...

Study: color-coding medications and syringes prevents errors during surgery

  • Patient Safety Monitor Insider, Issue 4, February 4, 2009

    A new study shows that transferring a peel-off colored sticker from a medication vial to a syringe...

UK: Cuts to trainee surgeons’ hours may threaten patient safety

  • Patient Safety Monitor: Global Edition, Issue 3, February 3, 2009

    The United Kingdom’s Royal College of Surgeons (RCS) have claimed that patients&rsquo...

Ireland: Constant overcrowding puts patients and their safety at risk

  • Patient Safety Monitor: Global Edition, Issue 3, February 3, 2009

    At Dublin’s Beaumont Hospital, nearly fifty patients have been treated on temporary beds at...

Australia: Queensland hospitals worst in patient safety

  • Patient Safety Monitor: Global Edition, Issue 3, February 3, 2009

    A recent report by the Productivity Commission found that Queensland hospitals show some of the...

Wales: Medical and patient safety errors increase in past year

  • Patient Safety Monitor: Global Edition, Issue 3, February 3, 2009

    A Freedom of Information request by Liberal Democrats has revealed that from 2007-2008, 191 deaths...

New Jersey bill proposes increased identification of hospitals that have committed errors

  • Patient Safety Monitor Insider, Issue 4, January 28, 2009

    As part of an expansion of the Patient Safety Act that went into effect in New Jersey four years...

Minnesota hospital uses "timeout towel" to prevent surgical error

  • Patient Safety Monitor Insider, Issue 4, January 28, 2009

    In an attempt to prevent wrong-site surgeries, Regions Hospital in St. Paul, MN, has taken a...

CA hospitals mortality rate data available

  • Patient Safety Monitor Insider, Issue 4, January 28, 2009

    California has published a study ranking hospitals based on their mortality rates, reports The Los...

Computer glitch causes medical errors for veterans nationwide

  • Patient Safety Monitor Insider, Issue 3, January 21, 2009

    Since August 2008, patients at Veterans Affairs (VA) health centers across the country have been...

Surgical checklist shown to reduce risk of error by one third

  • Patient Safety Monitor Insider, Issue 3, January 21, 2009

    A study released by the World Health Organization (WHO) last week shows that when implementing the...

Scotland’s government requires hospitals to cut C. diff in half

  • Patient Safety Monitor: Global Edition, Issue 0, January 20, 2009

    The Scottish government, working with infection experts, has announced a 15-point plan to help its...

Canada: Special investigation uncovers 27 additional deaths at Winnipeg hospital

  • Patient Safety Monitor: Global Edition, Issue 2, January 20, 2009

    Winnipeg Regional Health Authority will be forced to investigate and review the 2,577 deaths that...

United Kingdom: Recorded hospital errors rise 60% in just two years

  • Patient Safety Monitor: Global Edition, Issue 2, January 20, 2009

    According to figures obtained by The Daily Mail, 3,645 patients have died in the 2007/2008 year as...

Worldwide pilot study finds checklist reduces adverse events by a third

  • Patient Safety Monitor: Global Edition, Issue 2, January 20, 2009

    A pilot study in which eight hospitals across the globe implemented a new surgical checklist has...

Incoming Obama administration to push for electronic health records

  • Patient Safety Monitor Insider, Issue 2, January 14, 2009

    Although his inauguration does not take place until next week, President-elect Barack Obama is...

Medical devices lag behind technology outside of healthcare

  • Patient Safety Monitor Insider, Issue 1, January 7, 2009

    The inability for medical devices to communicate with each other is becoming a growing concern...

Pfizer and hospitals partner to trial system for reporting drug risks

  • Patient Safety Monitor Insider, Issue 1, January 7, 2009

    Pfizer has joined together with Brigham and Women’s Hospital and Massachusetts General...

Australia: Patient data could thwart medication dangers

  • Patient Safety Monitor: Global Edition, Issue 1, January 6, 2009

    The Australian Commission on Safety and Quality Healthcare is asking the Australian government to...

Ignored hospital repairs in UK place patients’ safety at risk

  • Patient Safety Monitor: Global Edition, Issue 1, January 6, 2009

    Little has been done to help the crumbling buildings and failing infrastructure of the United...

Australia: New patient e-cards to aid in patient information retention

  • Patient Safety Monitor: Global Edition, Issue 1, January 6, 2009

    Health Minister Katy Gallagher has called for patient electronic health cards for Canberra...

Hospital errors in New Jersey increase, but most likely due to better reporting

  • Patient Safety Monitor Insider, Issue 52, December 24, 2008

    In 2007, 72 people died in New Jersey hospitals due to preventable errors, says data from the third...

Australia: Handwashing, response teams part of patient safety initiative

  • Patient Safety Monitor: Global Edition, Issue 25, December 23, 2008

    Australian Health Minister John Della Bosca says that the government will require hospitals to...

Australia: Medical mistakes kill 28 in Victoria district

  • Patient Safety Monitor: Global Edition, Issue 25, December 23, 2008

    In the past year, medical mistakes have killed 28 patients in Victoria, Australia, according to the...

Sentinel Event Alert targets technology-related medical errors

  • Patient Safety Monitor Insider, Issue 51, December 17, 2008

    The Joint Commission has released its latest Sentinel Event Alert, this time looking at prevention...

Australia: Chemotherapy overdose prompts audit of medical equipment

  • Patient Safety Monitor: Global Edition, Issue 24, December 9, 2008

    After a four-year period in which 11 children were overdosed with a chemotherapy drug, the South...

UK: One in 10 patients die from medical errors

  • Patient Safety Monitor: Global Edition, Issue 24, December 9, 2008

    The House of Commons Health Committee received news that 40,000 patients die every year from...

Institute of Medicine suggests more non-working time for medical residents

  • Patient Safety Monitor Insider, Issue 49, December 3, 2008

    The Institute of Medicine (IOM) has asked U.S. hospitals to look at their resident programs and...

Minnesota develops rules for preventing surgical errors

  • Patient Safety Monitor, Issue 12, December 1, 2008

    When Minnesota’s hospitals outwardly recognized in 2007 that the state’s process for...

Scotland: Medical errors kill thousands, cost millions

  • Patient Safety Monitor: Global Edition, Issue 23, November 25, 2008

    A government-funded study published in the Scottish Medical Journal that reviewed case notes of 354...

Canadian hospital reused syringes for two decades

  • Patient Safety Monitor: Global Edition, Issue 23, November 25, 2008

    At High Prairie Health Complex, in northern Alberta, a handful of nurses have been injecting...

UK: National Patient Safety Agency recommends list of never events

  • Patient Safety Monitor: Global Edition, Issue 23, November 25, 2008

    The National Health Service’s National Patient Safety Agency (NPSA) is proposing a list of...

Scotland nurses’ poor math skills endanger patients

  • Patient Safety Monitor: Global Edition, Issue 23, November 25, 2008

    According to a government report, nurses’ numerical errors are putting patients in danger...

Newborn babies infected with MRSA, hospital trying to find cause

  • Patient Safety Monitor Insider, Issue 45, November 5, 2008

    St. John’s Riverside Hospital in Yonkers, NY is investigating the cause for seven newborn...

Australia: Handwashing campaign to counter hospital-acquired infections

  • Patient Safety Monitor: Global Edition, Issue 22, October 28, 2008

    By next year, the Australian Commission on Safety and Quality in Healthcare will launch a...

Australia: Doctors work 100 hours a week

  • Patient Safety Monitor: Global Edition, Issue 22, October 28, 2008

    An Australian Medical Association survey of 1,000 doctors reveals that they work between 50 and 100...

Canada: Toronto hospital cuts death rate in half

  • Patient Safety Monitor: Global Edition, Issue 22, October 28, 2008

    Scarborough Hospital, Canada's largest urban community hospital, has turned around its reputation...

Rand Corporation study endorses need for national unique patient identifiers

  • Patient Safety Monitor Insider, Issue 43, October 22, 2008

    Although its price tag would likely be $11 billion, unique patient identifiers (UPI) would...

Inspection of Scottish NHS leads to concerns over blood transfusions

  • Patient Safety Monitor: Global Edition, Issue 21, October 14, 2008

    Inspectors of National Health Service (NHS) Quality Improvement Scotland, which monitors Scottish...

Physicians more apt to admit obvious errors than less obvious ones

  • Patient Safety Monitor Insider, Issue 41, October 8, 2008

    Doctors are more likely to admit errors that are obvious than those that are less obvious, reports...

Ontario hospitals begin posting C. diff rates

  • Patient Safety Monitor: Global Edition, Issue 20, September 30, 2008

    On October 3, 2008, Ontario hospitals will begin posting infection rates of Clostridium difficile...

Increased patient population leads to concerns in Auckland

  • Patient Safety Monitor: Global Edition, Issue 20, September 30, 2008

    Auckland hospitals are short of patient beds, jeopardizing patient safety, reports the New Zealand...

Wrong knee operated on even after new protocol at RI hospital

  • Patient Safety Monitor Insider, Issue 39, September 24, 2008

    The state of Rhode Island suffered its eighth wrong site surgery within the past decade, when...

American and Middle Eastern hospitals join effort to improve patient safety

  • Patient Safety Monitor: Global Edition, Issue 19, September 16, 2008

    Hospital leaders from the United States, Israel, the Palestinian Authority, Jordan and Kuwait are...

Limitations on Toronto hospitals during SARS outbreak did not harm patients

  • Patient Safety Monitor: Global Edition, Issue 19, September 16, 2008

    Patients hospitalized during Toronto's SARS outbreak in 2003 did not suffer from the temporary...

After C. difficile outbreak, Scotland to sends teams to survey infection control

  • Patient Safety Monitor: Global Edition, Issue 19, September 16, 2008

    After a deadly outbreak of Clostridium difficile (C. difficile), which included 18 deaths and more...

Massachusetts lawsuit accuses doctor of negligence in prescribing a patient’s medication

  • Patient Safety Monitor Insider, Issue 37, September 10, 2008

    The liability of medical professionals may be broadened in a pending Massachusetts case, reports...

Sydney: Calls for transparency after 49 deaths

  • Patient Safety Monitor: Global Edition, Issue 18, September 2, 2008

    Two annual reviews of hospitals in the Sydney West Area Health Service that claim 49 patients died...