New Resources - Supplemental Learning: Medical Errors and Patient Safety

  

Medical Errors and Patient Safety

 

Section Contributor: Vivian Lee          

 

References

 

a.      Leape L, et al. Transforming healthcare: a safety imperative. British Medical Journal Quality & Safety, 2009; 18:424-428. http://qualitysafety.bmj.com/content/18/6/424.long

 

Introduction to five core concepts identified by the National Patient Safety Foundation to guide improvement in healthcare safety: transparency, care integration, patient/consumer engagement, restoration of joy and meaning in work, and medical education reform. (SBP 1, 2, 3)

 

b.      To err is human: building a safer health system.  Eds. Linda T Kohn, Janet M Corrigan, Molla S Donaldson . Institute of Medicine Consensus Report:  http://www.iom.edu/Reports/1999/to-err-is-human-building-a-safer-health-system.aspx for links to full and brief reports; full report also linked from www.nap.edu/books/0309068371

 

Landmark report from IOM describing the prevalence, cost and types of errors that exist in the healthcare system and provides a strategy by which the system and individuals can work to reduce preventable medical errors. (SBP 1, 2, 3)

 

c.       Leonard MS. Patient Safety and Quality Improvement: Medical Errors and Adverse Events. Pediatrics In Review. http://pedsinreview.aappublications.org/cgi/content/full/31/4/151

 

 A review of terminology used in safety and adverse events, introduction of some prevention strategies. (SBP 1, 2, 3)

 

d.      Starmer AJ,et al. (I-PASS Study Group).  Changes in medical errors with a handoff program.

N Engl J Med. 2015 Jan 29;372(5):490-1. doi: 10.1056/NEJMc1414788

 

e.      William, PM. Techniques for root cause analysis.  Baylor University Medical Center Proceedings  BUMC Proceedings 2001; 14:154-157.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/

 

An article detailing steps to performing a root cause analysis using a case-based example. (SBP 1, 2, 3)

 

f.        Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 35.   http://www.ncbi.nlm.nih.gov/books/NBK2652/

 

Online Resources

 

a.      Institute for Healthcare Improvement Open School courses on Patient Safety.   http://app.ihi.org/lms/onlinelearning.aspx

 

Excellent modules introducing learners to basic concepts of patient safety and tools used in reviewing adverse events.   Requires registration (free). (SBP 1, 2, 3)

 

b.      The Joint Commissions Patient Safety Initiatives.   http://www.jointcommission.org/topics/patient_safety.aspx

 

The Joint Commissions portal for patient safety initiatives, including information about the National Patient Safety Goals and other resources. (SBP 1, 2, 3)

 

 

c.       Agency for Healthcare Research and Quality (AHRQ)  Patient Safety Primer.  http://psnet.ahrq.gov/primerHome.aspx 

 

AHRQs website providing resources for several key concepts in patient safety including safety culture, medication errors, handoffs and signouts, and error disclosure, among many more.   Each primer defines the topic, provides background education, and offers links to relevant guidelines, evidence, commentaries and toolkits. (SBP 1, 2, 3)