jspf journal 2013 report patient safety deaths

When was Journal of patient safety 13 (1) published?

Journal of Patient Safety13 (1):1-5, March 2017. Separate multiple e-mails with a (;). Thought you might appreciate this item (s) I saw at Journal of Patient Safety.

What is the value of E-Reporting in patient safety research?

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.

What is the content structure of a patient safety event report?

3.2 The Content Structure of Patient Safety Event Reports Patient safety event reports generally contain structured information such as the time and site of occurrence, role of the participants (e.g. physician, nurse, or technician), patient demographic and clinical attributes, as well as a classification of the severity and type of event.

What are the different aspects of patient safety?

This report presents different aspects of patient safety in terms of root cause analysis (RCA) and risk management, the role of human resources, the role of professionalism, the necessity of informing the parents (disclosure of medical errors), and forensic medicine with focus on ethical aspects.

Why is the present estimate of the number of lethal PAEs so much higher than the highest estimate (98,000)?

How many people die from PAEs in a year?

What is preventability in a case?

What are contextual errors?

How many patients were treated in tertiary hospitals in 2004?

How many deaths are preventable harm?

How is medical care complex?

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CDC Asked to List Medical Error as ‘3rd Most Common Cause of Death in ...

CDC Asked to List Medical Error as ‘3rd Most Common Cause of Death in ... ... .

A new, evidence-based estimate of patient harms associated with ...

Objectives: Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011.

‘Medical Errors’ Are the Third Leading Cause of Death

The British Medical Journal recently published a study that revealed “medical errors” are now the third-largest contributor to death in the5 United States, behind only heart disease and cancer, respectively. According to the research, the Centers for Disease Control and Prevention tracks the leading causes of death, but there are no direct reports of deaths...

Why is estimating error related mortality important?

Why is estimating error-related mortality so important? It obviously represents the most severe outcome that can be caused by a wide variety of preventable complications including the following: bed ulcers, infections, embolism, surgical error, misdiagnosis, etc. Unlike other adverse outcomes, mortality can be unequivocally defined. Granted, the overall metric that determines risk and preventability adds layers of complexity, at least everyone agrees with the definition of the event. Many argue over when an infection occurs or when a fall should be a reportable event but death is a definitive and nondebatable outcome. Prevention mandates that institutions invest in patient safety and foster a culture of safety among staff and administration.

What ties the occurrence of preventable adverse events and mortality together?

What ties the occurrence of preventable adverse events and mortality together is the willingness and determination of facilities to adopt a culture of safety and invest in patient safety. The adoption of preventive protocols is further hindered by the United States' fragmented, nonuniform healthcare systems composed of facilities with differing philosophies and administrative structure.

How many preventable deaths were there in 2013?

September 2013: John James in the Journal of Patient Safety estimated that there were between 210,000 and 440,000 preventable hospital deaths. 3 This study has been highly quoted in the literature and reopened the discussion regarding preventable mortality from medical errors. What is most striking is that this report did not have its genesis within the healthcare industry but was from a National Aeronautics and Space Administration scientist, John James, who lost his son because of a medical error.

What is causality of death?

Causality of death: The contention has been made that researchers did not demonstrate that the observed preventable adverse events caused the deaths, which have been attributed to them. Proving causality of each incident has not been a standard used by the healthcare industry for other important public health matters.

How many deaths were predicted in 1999?

Makary and Daniel analyzed 4 different studies and all 4 projected preventable mortality well over the 44,0000 to 98,000 projected deaths in the 1999 Institute of Medicine Report. 8 The Healthgrades study 9 used PSIs, but only for a portion of its data. The other 3 studies used the Global Trigger Tool to identify events. In 2 of these studies, preventable harm was determined by a additional chart review. 10,11

What does the NTSB do?

The NTSB calculates statistics and performance of the airline industry only on the basis of airline carriers in the United States. Even if a foreign plane crashes in the United States, it is not included. The NTSB realizes that safety oversight and administration vary widely between countries. 5.

How does the leapfrog measure hospital safety?

The LeapFrog Group measures hospital safety using a total of 30 publicly reported metrics including laboratory reporting of Methicillin-resistant Staphylococcus aureus and Clostridia Difficile and 5 patient survey measurements (Hospital Consumer Assessment of Healthcare Providers and Systems metrics). 12 Of the 30 metrics, Winters et al 6 question 2 which comprise approximately 5% of the composite score. This argues in favor of the overall validity of the Leapfrog estimate, not against it. The Johns Hopkins researchers, who performed the Leapfrog study, also discussed how their findings are likely conservative, because they applied mortality rates only to a subset of known safety problems.

What should not be used in a care team announcement?

Moreover, irritating phrases such as “It happens” and “Nothing has happened though” should not be used.

Why can't we hide medical errors?

Although anger under such circumstances is a natural reaction, we cannot hide medical errors because of fear of parents’ reaction. Moreover, parents’ anger would be more severe if they found out that the hospital personnel have concealed the truth.

How to reduce the possibility of such events in clinical settings?

The most important step to reduce the possibility of such events in clinical settings is to establish policies and procedures that work best for each ward. Furthermore, the continuous training of the personnel in patient safety, steady supervision, and controlling the efficacy level of the performed actions are some other steps that can be taken in this regard. For instance, in this case, frequent checking of the incubator door, the use of two locks, and explanation of safety tips regarding the incubator to the staff are also important. Furthermore, evaluation and constant controlling of compliance with patient safety rules, and feedback are also necessary.

What is the moral value of patient safety?

It can be studied as a practical value, in the sense that the main focus is its positive outcomes and benefits. It can also be studied as a moral value by focusing on the protection and promotion of humanity and human dignity. It should be emphasized that both aspects are important in the health system. From a professional point of view, moral values in patient safety are not separated from basic medical obligations, but are so central that they may be the source of other moral values emphasized in medicine. This means that patient safety is closely related to the concept of human dignity and all patient safety measures taken must insure the protection of human’s dignity (10). In other words, the responsibility of the health care staff and professional commitment, in general, are closely related to human dignity (11).

Why is trustworthiness important?

From an ethical perspective, the value of trustworthiness is a prerequisite of successful risk management. This value is connected to safety culture since it refers to physical safety, psychological safety, and cultural safety. Thus, the managers’ responsibility is to create mental and physical safety settings based on openness in order to promote patient safety and care quality. Furthermore, it is important for the managers to encourage multidisciplinary collaboration to facilitate transparent reporting (10).

How to reduce the incidence of patient injuries?

Searching for the causes and finding the right solution, in other words, the basic analysis of the incident is one of the initial and essential measures taken to decrease the incidence of patient injuries. It should be noted that the mentioned process must be free of any bias and should focus on finding the main cause and resolving it instead of identifying the responsible person. One way of preventing such events is to have a special guideline for reporting the event in a suitable organized ethical atmosphere without accusing anyone. Indeed, fear of blame, penalties, limited organizational support, inadequate feedback, and lack of knowledge about the associated factors are some of the barriers to reporting medical errors in hospitals (12).

What is the most common cause of injury in healthcare?

Since 2004, with the beginning of the patient safety project, so far 140 countries have attempted to improve their patients' safety plans in their own health system (7). The most common cause of injury is medication errors and falling. Although falling includes 21% of total incidents, only 4% of them are serious. Meanwhile the neonatal falling statistics in the USA is 1.6-4.4 in 10,000 live births, an estimated 600-1600 falling incidents in a year. These cases are often the result of shortcomings in systems and processes, organizational complexity and ambiguity, and poor communication (8, 9).

How many respondents were there in the 2021 SOPS database?

This chapter describes the characteristics of the 87,856 respondents in the 2021 SOPS Hospital 2.0 Database (Tables 4-1 to 4-3).

What is SOPS 2.0?

In response to requests from hospitals interested in comparing results with those of other hospitals on the Surveys on Patient Safety CultureTM (SOPS®) Hospital Survey 2.0, the Agency for Healthcare Research and Quality (AHRQ) established the SOPS Hospital Survey 2.0 Database. The SOPS Hospital Survey 2.0, released by AHRQ in 2019, is a different version than the original SOPS Hospital Survey 1.0. The SOPS Hospital Survey 2.0 has fewer items and item wording is different than the 1.0 survey, as well as the names of some composite measures. More information about the 2.0 survey can be found on the AHRQ website at

How many hospitals are in the SOPS database 2021?

The 2021 SOPS Hospital 2.0 User Database Report is the first database based on voluntarily submitted 2.0 survey data from 1 72 hospitals and includes 87,856 provider and staff respondents. Submitting hospitals , which included some hospitals that participated in the pilot study, administered the 2.0 survey between November 2018 and October 2020. Most of the hospitals (85%) administered the 2.0 survey during the COVID-19 pandemic (March 2020 through October 2020), which may have affected their survey scores.

How many respondents are there in a hospital?

Average number of respondents per hospital (range: 26 to 4,686)

Why can't you add 100 percent to a percentage?

Percentages may not add to 100 percent due to rounding.

Is the SOPS 2.0 version the same as the original?

The SOPS Hospital Survey 2.0, released by AHRQ in 2019, is a different version than the original SOPS Hospital Survey 1.0. The SOPS Hospital Survey 2.0 has fewer items and item wording is different than the 1.0 survey, as well as the names of some composi te measures.

What is patient safety culture?

Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient safety. Patient safety culture can be measured by determining what is rewarded, supported, expected, and accepted in an organization as it relates to patient safety (see Figure 1). Figure 1.

Why is the present estimate of the number of lethal PAEs so much higher than the highest estimate (98,000)?

19 It is also possible that the frequency of preventable and lethal patient harms has increased from 1984 to 2002–2008 because of the increased complexity of medical practice and technology, the increased incidence of antibiotic-resistant bacteria, overuse/misuse of medications, an aging population, and the movement of the medical industry toward higher productivity and expensive technology, which encourages rapid patient flow and overuse of risky, invasive, revenue-generating procedures. 31–33

How many people die from PAEs in a year?

There was much debate after the IOM report about the accuracy of its estimates. In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAEs in hospitals. Any of the estimates demands assertive action on the part of providers, legislators, and people who will one day become patients. Yet, the action and progress on patient safety is frustratingly slow; however, one must hope that the present, evidence-based estimate of 400,000+ deaths per year will foster an outcry for overdue changes and increased vigilance in medical care to address the problem of harm to patients who come to a hospital seeking only to be healed.

What is preventability in a case?

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.”.

What are contextual errors?

Contextual errors occur when a physician fails to take into account unique constraints in a patient’s life that could bear on successful, postdischarge treatment. For example, the patient may lack the cognitive ability to comply with a medical treatment plan or may not have reasonable access to follow-up care. 16 Diagnostic errors resulting in delayed treatment, the wrong treatment, or no effective treatment may also be considered separately, although a small subset of these might be included as errors of commission or omission. For example, a diagnostic error may lead to harm from errors of commission by overtreatment or mistreatment of the patient until the mistake is discovered. The apparent eagerness of the U.S. health-care industry to over diagnose patients often leads to harmful consequences for patients. 17

How many patients were treated in tertiary hospitals in 2004?

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 ...

How many deaths are preventable harm?

Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm.

How is medical care complex?

Medical care in the United States is technically complex at the individual provider level, at the system level, and at the national level. The amount of new knowledge generated each year by clinical research that applies directly to patient care can easily overwhelm the individual physician trying to optimize the care of his patients. 1 Furthermore, the lack of a well-integrated and comprehensive continuing education system in the health professions is a major contributing factor to knowledge and performance deficiencies at the individual and system level. 2 Guidelines for physicians to optimize patient care are quickly out of date and can be biased by those who write the guidelines. 3–5 At the system level, hospitals struggle with staffing issues, making suitable technology available for patient care, and executing effective handoffs between shifts and also between inpatient and outpatient care. 6 Increased production demands in cost-driven institutions may increase the risk of preventable adverse events (PAEs). The United States trails behind other developed nations in implementing electronic medical records for its citizens. 7 Hence, the information a physician needs to optimize care of a patient is often unavailable.