35 hours ago Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, … >> Go To The Portal
Objectives: Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. Unfortunately, the value of e-reporting system (a software or web server based platform) in patient safety research is greatly overshadowed by low quality reporting.
Despite increased attention toward the quality of health care services, there are still numerous threats to patient safety in healthcare settings. Since patient safety is multidimensional and grounded in ethical and legal imperatives, both ethical and legal challenges should be taken into account.
Review studies of electronic patient safety event reporting systems implemented or still in use at healthcare systems or patient safety organizations; Studies introducing the process of developing an electronic patient safety event reporting system. Studies were excluded if one of the following applied:
A patient safety event is defined as any process, act of omission, or commission that results in hazardous healthcare conditions and/or unintended harm to the patient [ 1]. Reporting patient safety events is a useful approach for improving patient safety [ 2].
In a somewhat similar study published in March 2011 in the journal Health Affairs, investigators examined the medical records of 795 patients treated in 1 of 3 tertiary hospitals in the month of October 2004. 18 These hospitals had been recognized for their efforts to improve patient safety. The investigators also used the GTT to discover adverse ...
Errors of communication can occur between 2 or more providers or between providers and patient. One example of a lethal error of communication between provider and patient occurred when cardiologists failed to warn their 19-year-old patient not to run.
All studies used a 2-tier approach that consisted of screening of medical records by nonphysicians, usually nurses or pharmacists, to flag suspect events. In the second tier, physicians examined the suspect events to determine if a genuine adverse event had occurred and, if so, the level of seriousness of the event.
A pilot study by the OIG was published in 2008 in an effort to explore the effectiveness of search methods for adverse events. 21 As noted in the methods section, this study relied on 5 search methods for flagging potential adverse events in medical records but did not specify whether such events were preventable.
The prevailing view is that “preventability” of an adverse event links to the commission of an identifiable error that caused an adverse event. Adverse events that cannot be traced to a likely error should not be called “preventable.”.
As ProPublica reported, Denham also served in other prominent patient safety posts — most notably as co-chairman of a committee that set guidelines for the National Quality Forum, a nonprofit group that endorses best practices that are widely adopted throughout the healthcare community.
He ran a nonprofit patient safety organization and a for-profit consulting business, but Denham wasn't a practicing physician and didn't have strong academic credentials.
The Institute of Medicine (IOM) released a report in 1999 entitled "Man is fallible: create a safe health system" in relation to the incidence of medical errors in United States, and consequently, initiated widespread international change in the field of patient safety (2).
Despite increased attention toward the quality of health care services, there are still numerous threats to patient safety in healthcare settings. Since patient safety is multidimensional and grounded in ethical and legal imperatives, both ethical and legal challenges should be taken into account.