Quality & Patient Safety

Quality & Patient Safety Articles by Topic: Adverse Events

Connecticut hospitals reporting fewer adverse events; many go uninvestigated

  • Patient Safety Monitor Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 (Briefings on Patient Safety), 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 (Briefings on Patient Safety), 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 (Briefings on Patient Safety), 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 (Briefings on Patient Safety), 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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 Alert, 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...