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  • Patient Safety Research and Resources

  • Hospitals: 2012 National Patient Safety Goals
    (Link to Outline, Chapters, and Easy-to-read version)
    The purpose of the National Patient Safety Goals is to improve patient safety. The Goals focus on problems in health care safety and how to solve them. Goals include (but are not limited to): correctly identifying patients, preventing infection, using medicines safely, improving staff communication, identifying patient safety risks, and more.

    2009 National Healthcare Quality and Disparities Reports
    The National Healthcare Quality Report tracks the health care system through quality measures, such as the percentage of heart attack patients who received recommended care when they reached the hospital or the percentage of children who received recommended vaccinations. The report measures trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The report presents, in chart form, the latest available findings on quality of health care.

    The Joint Commission Sentinel Event Data Event Type by Year
    1995-Third Quarter 2010
    This presentation provides an overview of sentinel events reviewed by The Joint Commission from 1995 through the third quarter of 2010. The report presents, in chart form, event types as reviewed by The Joint Commission, in areas including anesthesia-related, delay in treatment, medication error and others. The report also provides a summary of most frequently reviewed sentinel event categories from 2008 to third quarter 2010.

    The Joint Commission Sentinel Event Data Root Causes by Event Type
    2004-Third Quarter 2010
    This Joint Commission presentation provides descriptions of the most commonly identified root cause categories contributing to reviewed sentinel events, including assessment, communication, human factors and more. It also includes root cause data for events including anesthesia-related, delay in treatment, medication error and other kinds of events, from 2004 through the third quarter 2010.

    Serious Reportable Events in Massachusetts Acute Care Hospitals 2009
    This report presents patient safety data as reported to the Massachusetts Department of Public Health by hospitals in Massachusetts in 2009. Event categories are based on the National Quality Forum's list of twenty-eight discrete adverse medical events, know as serious reportable events (SREs). The report provides data on the most common types of events as well as total events by hospital. The goal of the report is to gain a greater understanding of why events happen and how they can be prevented in the future.

    Adverse Health Events in Minnesota Sixth Annual Public Report (January 2010)
    This publication provides an overview of events reported by Minnesota facilities, from Oct. 7, 2008 through Oct. 6, 2009, as well as findings. Information is provided by event category and also by facility. A column on responding to adverse health events is also included. The report offers a summary of progress made in reducing harm to patients and in addressing some of the most common system breakdowns that can lead to adverse events.

    Beyond the Count: Preventing Retention of Foreign Objects, Pennsylvania Patient Safety Advisory

    Published in June 2009 by the Pennsylvania Patient Safety Authority, this article examines risk factors for retained foreign objects following surgery. It also addresses the role of human factors analysis to uncover system vulnerabilities, and describes risk reduction strategies.

    "#2 on the Joint Commission List: Retained Foreign Objects" from OR Connection magazine
    This article offers an overview of the issue of retained foreign objects (RFOs). It includes Joint Commission recommendations for when a foreign object is retained in the patient, as well as potential reasons for and ways to avoid RFOs. A brief overview of products that can minimize the risk of RFOs is also included.

    Massachusetts Department of Public Health/Patient Safety Update on Retained Foreign Objects (August 2010)
    Distributed to all Massachusetts hospitals required to report serious reportable events (SREs) to the Department of Public Health, this publication provides an overview of Massachusetts SRE numbers as compared to some other states. It also offers two case studies describing what was reported and the initial changes made as a result of the hospitals' analyses of the events. The American College of Surgeons' recommendations to prevent the retention of foreign objects are also included.

    Ensuring Safe and Effective Use of Medication and Health Care
    As physicians, most of our time in medical education and professional development is focused on getting the diagnosis and treatment plan right. All that work is meaningless without the dismount, which, in medicine, requires enabling the patient to understand and act in ways that maximize health outcomes. Physicians, nurses, health systems, health plans, and pharmaceutical companies frequently botch the handoff of responsibility from the health care system to the patient. As a result, countless numbers of people may be injured or inadequately treated.

    ECRI Institute Releases Top 10 Health Technology Hazards for 2011
    (Available for free download with registration)
    Where do you start when trying to minimize the risks from healthcare technology? ECRI Institute (, an independent nonprofit that researches the best approaches to improving patient care, helps hospitals answer this question with the release of its 4th annual list of Top 10 Health Technology Hazards for 2011. The list features the top 10 health technology hazards that warrant critical attention by hospitals and other healthcare organizations in the coming year.

    Set of Specific Interventions Rapidly Improves Hospital Safety 'Culture'; Studies Suggest Culture Change Necessary for Sustained Patient Safety
    A prescribed set of hospital-wide patient-safety programs can lead to rapid improvements in the "culture of safety" even in a large, complex, academic medical center, according to a new study by safety experts at Johns Hopkins. Establishing a sustained culture of safety in health care has been associated with better outcomes for patients in previous studies.