Medical errors

Innovations

Toolkit-Supported Safety Rounds With Staff and Patients Enhance Reporting of Medical Errors and Near Misses 02/20/08

The Dana-Farber Cancer Institute uses safety rounds with staff and patients, supported by a toolkit, to promote a culture of safety and reduce medical errors by proactively identifying and addressing potential safety problems.

Medical Team Training Using Crew Resource Management Principles Enhances Provider Communication and Stimulates Improvements in Patient Care 02/11/08

A comprehensive medical team training program supported by crew resource management principles adopted from the aviation industry was developed and implemented in 79 Veterans Affairs Medical Centers, resulting in a measurable improvement in communication and patient care in 10 participating facilities that have at least a year's experience with the program.

Comprehensive Initiative to Create a Culture of Safety Significantly Reduces Harm Caused by Medical Errors, Mortality, Length of Stay, and Hospital-Acquired Pneumonia and Infections 02/11/08

Sentara Healthcare launched a program designed to create a strong culture of safety. The initiative includes an assessment of the existing safety culture, establishment of goals related to improved safety, the development of specific strategies to identify and correct safety problems, and the use of ongoing processes and systems to monitor progress and encourage continued improvement.

Patient- and Family-Activated Response Team Averts Potential Problems and Generates High Levels of Patient, Family, and Staff Satisfaction 01/23/08

The University of Pittsburgh Medical Center Shadyside implemented a Condition Help program that patients or their family members can activate via a telephone call when the patient's condition is deteriorating; the call immediately brings in a rapid response team to assess and manage the situation and provide treatment as needed.

Teamwork Enhancement Program Improves Obstetric Care in a Military Hospital 12/27/07

An evidence-based teamwork and communication program implemented in the labor and delivery unit of Madigan Army Medical Center led to an improved care process.

Patient Safety Alert System That Uses Principles From Auto Manufacturing Increases Reporting and Improves Safety in a Medical Center 12/26/07

Virginia Mason Medical Center instituted a patient safety alert system that requires all staff who encounter a situation likely to harm a patient to make an immediate report and cease any activity that could cause further harm.

Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety 12/13/07

A multifaceted initiative known as the Good Catch Program dramatically increases the reporting of events that could potentially cause harm and spurs the development of action plans designed to address the common causes of potential errors.

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