Medical errors

Innovations

Statewide Health Information Exchange Generates High Levels of Participation and Many Reports of Improved Quality and Efficiency 02/26/13

The Delaware Health Information Network is the country's first operational statewide health information exchange. Facilitated by State legislation and overseen by a board and committee structure,...

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart 10/30/12

Children's Hospital Colorado requires clinicians in all inpatient and outpatient facilities to confirm any order entered into its computerized order entry system through a popup verification...

State-Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction 08/31/12

As mandated by State law, the California Department of Health Services requires acute care hospitals to maintain minimum nurse-to-patient staffing ratios. Required ratios vary by unit, ranging...

Multidisciplinary Hospital Team Proactively Meets With Patients and/or Families, Allowing Them to Better Deal With Unexpected Deaths and Other Negative Events 02/06/12

The St. Joseph Mercy Hospital emergency department operates the Next Step Program, which supports patients and family members after an unexpected death or other unexpected, negative event. A team...

Alerts and Decision Support for Abnormal Laboratory Values Do Not Improve Clinical Management or Reduce Adverse Events 01/11/12

Residents and on-call physicians on two internal medicine teaching units received alerts whenever a patient had any of six abnormal laboratory values, along with a link to decision support related...

QualityTools

AHRQ Common Formats 04/24/14

The Common Formats, authorized by the Patient Safety and Quality Improvement Act of 2005, facilitate Patient Safety Organization (PSO) collection of patient safety work product from health care providers in a standardized manner. Use of these...

Disclosure Toolkit and Disclosure Culture Assessment Tool 04/26/12

This toolkit and self-assessment tool help health care organizations develop a culture that supports respect and effective communication with patients and families around adverse events. The Disclosure Toolkit provides selected tools, literature...

Tools for Building a Clinician and Staff Support Program 04/26/12

These tools and resources guide health care facilities in organizing institution-wide support for clinicians following adverse events. Included is a toolkit for organizations to use regardless of where they are on the spectrum—from those in the...

Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture 01/20/11

This document contains references to Web sites that provide practical resources hospitals can use to implement changes to improve patient safety culture and patient safety. This resource list is not exhaustive but is provided to give initial...

MedWatch Safety Alerts 11/11/10

MedWatch is a free tool for providers and consumers that offers many ways to help them stay informed about the medical products they prescribe, use, or dispense every day. MedWatch provides safety alerts directly to users through the channel they...

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