Resources
Tools
Download a categorized Microsoft Excel spreadsheet listing the safety tools available free from the Safety Web. (344 KB) (.xls)
Reference readings
Reference abstracts may be located through a National Library of Medicine search using the link at the end of this listing.
- Brennan, TA, Leape LL, Laird N, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-6.
- Thomas, EJ., Studdart, DM., Newhouse, JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999; 36(3):255-64.
- McDonald CJ, Weiner M, Hui, SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA 2000; 284(1):93-95.
- Leape L. Institute of Medicine’s error figures are not exaggerated. JAMA 2000; 284(1):95-97.
- CDC NNIS System. Nosocomial infection rates for interhospital comparison: Limitations and possible solutions. Infect Control Hosp Epidemiol 1991; 12:609-21.
- Extraordinary similarities exist between infection control and medication error prevention. ISMP Medication Alert. November 17, 1999.
- Haley RW, Haley RW, Culver DH, White JW, Morgan WM, Emori TG, et. al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182-205.
- CDC 2000. Monitoring hospital-acquired infections to promote patient safety-US 1990-1999. MMWR March 3, 2000 49(08);149-153.
- Leape, L. Kabcenell A, Berwick DM, Roessner J. Reducing Adverse Drug Events: Breakthrough Series Guide. Boston, MA: Institute for Healthcare Improvement Press, 1998.
- Pugliese G. Avoiding Common Safety Mistakes: Best Practices for a Safer Environment. Outpatient Surgery Dec 2002.
http://www.ncbi.nlm.nih.gov/pubmed
Publications, resources and safety-related organizations
See Links for additional safety organizations.
Accelerating Change Today for America’s Health (ACT)
ACT is a collaborative initiative of the National Coalition on Health Care and the Institute for Healthcare Improvement. It aims to improve the quality of healthcare in the US through identifying "best practices" and administrative and clinical innovations. ACT has produced and distributed a monograph: Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine. Profiles of nine institutions and organizations that made a commitment to change and made a difference, plus resources and other readings are described in the monograph. The booklet may be downloaded; nine stories are listed below with brief summaries described by a few of the stories.
- Can We Make Health Care Safe? By Lucian L. Leape, M.D.
- Back from the Brink: Making Chemotherapy Safer, The Dana-Farber Cancer Institute
- A Government Health System Leads the Way, The VA Health System
- Making Doctors Computer Literate, Brigham and Women’s Hospital
- What’s in a Name? When it Comes to Drugs -- Lots, Bristol-Myers Squibb
- Tackling Medication Errors Head On, Luther-Midelfort Hospital
- Making Mistakes Harder to Make, Fairview Health Services
- A Dummy Helps Pave the Way to Better Medicine, VA/Stanford Simulation Center
- A Medical Specialty Blazes a Trail, Anesthesiology was first in addressing medical errors
American Hospital Association (AHA)
- Quality advisory on Improving medication safety
- Patient Safety Assessment Tool
- Provides a list of successful practices for immediate implementation
- Resources on related topics
Medication error information and resources are available from the home page. Information may be obtained from listed Web site; a password may be required for some information. Go to: "Quality advisory" Link to:
http://www.aha.org/aha_app/index.jsp
Agency for Healthcare Research and Quality (AHRQ),
formerly Agency for Health Care Quality and Policy and Research (AHCPR)
*Special report
AHRQ released an Evidence Report/Technology Assessment Number 43, "Making Health Care Safer: A Critical Analysis of Patient Safety Practices" in July 2001. A summary of the analysis of 79 practices may be reviewed in the Summary report appended here, as well as the Appendix listing all 79 practices tabulated with ratings. The full report is lengthy (2107 KB) and may be downloaded from this Web site. You may also go to the AHRQ link for the report.
AHRQ audio newscast series (New)
This site provides the Agency's latest health care research findings, news, and information. This site enables viewers to also hear the newscasts through a computer or permit a download to a portable digital player such as an iPod.
Anesthesia Patient Safety Foundation (APSF)
- Clinical information, newsletters, and other safety links
- Direct access to reprint from J Clin Anesth 1993: Administrative guidelines for response to an adverse anesthesia event
- Anesthetic management of the latex-allergic patient. A perioperative interactive linked on-line tutorial from Cleveland Clinic Foundation.
- The documents may be downloaded form listed Web site. Go to: "Clinical", "Adverse Event Protocol."
http://www.apsf.org/resource_center/clinical_safety/adverse_event.mspx
American Society of Healthcare Risk Management (ASHRM)
ASHRM provides a number of publications and videos for minimal fees.
- Disclosure of Medical Errors: Demonstrated Strategy to Enhance Communication, a one-hour video produced by ASHRM, focuses on practical risk management strategies to approach disclosure. The video is available for $50 to ASHRM members, $60 to non-members. Catalog #169520. Online order: https://www.hospitalconnect.com/ashrm/resources/products.html
- Pearls for Medication Error Reduction is a pocket guide to medication error reduction. It covers issues such as the five most common medication errors, system errors, high risk drugs, problematic devices, training, and effective communication. The guide is available for $15 for ASHRM members, $20 for non-members. Packs of five are available to members for $45, non-members, $55. Catalog # 178555. Online order: https://www.associationstores.org/OA_HTML/ibeCCtpSctDspRte.jsp?section=10327
- Phone order to AHA: Call 800.242.2626 and provide catalog number.
ASHRM also provides:
- Multiple resources related to all aspects of patient safety (for example, use of restraints)
- Access to publications
- Summary and tracking of federal and state legislative activity
CDC NNIS (now known as NHSN)
The National Nosocomial Infections Surveillance (NNIS) System is a cooperative effort that began in 1970 between the Centers for Disease Control and Prevention (CDC) and participating hospitals to create a national nosocomial infections database. The site has been revised and renamed the National Healthcare Safety Network (NHSN) and includes healthcare worker and data beyond hospitals, such as dialysis centers. A comparison of NNIS and NHSN may be downloaded. The database is used to:
- describe the epidemiology of nosocomial infections
- describe antimicrobial resistance trends
- produce nosocomial infection rates to use for comparison purposes
The data are collected uniformly by trained infection control personnel using surveillance protocols that target inpatients at high risk of infection, and are reported routinely to CDC, where they are aggregated into the database.
NNIS-NHSN home http://www.cdc.gov/ncidod/dhqp/surveillance.html
NNIS-NHSN Comparison http://www.cdc.gov/ncidod/dhqp/pdf/nhsn/NHSN_NNISCompare.pdf
NNIS-NHSN publications and reports: http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html
Center for Medication Safety and Clinical Improvement
Inter-professional Conference on Pain Management and Sedation
Proceedings from The Sixth Conference Center for Medication Safety and Clinical Improvement Philip J. Schneider, MS, FASHP, Editor. November 17-18, 2005, San Diego, CA. Nationally recognized experts from different health professions focused on current issues and opportunities in postoperative pain management and sedation in intensive care patients.
These documents summarize the information presented on topics related to pain management and patient-controlled analgesia (PCA) with regard to assessment, risk factors for opioid-related adverse events, respiratory monitoring and clinical improvement of the PCA process. A second document summarizes the information presented on sedation therapy with regard to safety concerns, criteria for determining best practices, guidelines, assessment, nursing issues, and new administration and monitoring technologies that can help improve safety and quality of care. Conference reports are published by www.cardinalhealth.com.Center for Medication Safety and Clinical Improvement April 2006.
Pain Management and Patient-Controlled Analgesia: Improving Safety and Quality of Care
(.pdf) (625 KB)
- Pain Management and PCA
- Risk Factors
- Respiratory Monitoring
- Clinical Improvement of the PCA Process
- Roundtable Discussion
Sedation Therapy: Improving Safety and Quality of Care (.pdf) (1.5 MB)
- Issues and Opportunities: Assessment of Sedation/Delirium/Pain
- Sedation Management: Medications/Techniques
- Administration and Monitoring: New Technologies
ECRI Medical Device Safety Reports
- A nonprofit health services research agency. Reports and advisories garnered by ECRI on device-associated problems are collated into a database.
- Abstracts on medical device reports and recommendations based on ECRI findings by searching on device types and /or types of risk.
Equip for Quality – Web-based tool uses patient data to reduce
risk and improve health outcomes in long-term care facilities
EQUIP for Quality is a web-based quality improvement and risk management tool for long-term care facility and nursing home administrators and care staff. The tool was developed by AHRQ-funded patient safety grantee, Christie Teigland, PhD, Director of Health Informatics and Research at the New York Association of Homes and Services for the Aging (NYAHSA). It uses existing nursing home resident data collected as part of standardized patient evaluations on admission and at regular intervals, as required by the Centers for Medicare and Medicaid Services’ Minimum Data Set (MDS). The wealth of rich clinical data readily available from the MDS can help nursing staffs better understand changing resident characteristics and risk factors, lending new insights to manage the multiple chronic conditions common to the frail elderly. Using MDS data, the tool allows nursing home staff to:
- Generate resident-specific reports;
- Identify risk levels through predictive modeling for adverse outcomes, such as falls and pressure sores, thereby making them easier to prevent; and
- Produce individualized risk profiles, based on scientific evidence, that summarize the data needed to make timely, informed care decisions.
In addition, feedback reports help evaluate success in preventing adverse outcomes. According to an April 29, 2005 article in the online version of Government Health IT, one 300-bed New York state nursing home reduced the number of falls among its patients from 93 to 53 over a six-month period, and another New York nursing home using the tool received a $30,000 reduction in its annual liability insurance premium. Access the tool on the EQUIP for Quality website at http://www.equipforquality.com/.
* No official endorsement of this tool by the Agency for Healthcare Research and Quality, the Department of Health and Human Services, is intended or should be inferred.
Food and Drug Administration (FDA)
Selected examples of other FDA resources
- Workshop presented January 8, 1998 at NIH. Minimizing medical product errors – a systems approach Provides an industry and FDA perspective
- Improving Patient Care by Reporting Problems with Medical Devices’ is available in pdf
- The clinical impact of adverse event reporting is available in pdf; CME and CEUs provided
The selections may be downloaded at listed Web site. Go to: "CDRH" "Workshops"
Institute for Healthcare Improvement (IHI)
- Co-sponsor of initiative: Accelerating Change Today (A.C.T.) for America’s Health. Focuses on best practices and breakthrough innovations in health care.
- Link to co-sponsor, National Coalition on Health Care.
- Report "Reducing medical errors and improving patient safety: success stories from the front lines of medicine." This report, released in February 2000, is available from IHI and the National Coalition for Healthcare. The complete document may be downloaded from the listed web site.
- Multiple links to participating organizations and related resources, including Dr. Berwick’s 1998 Presentation at the Annenberg Center conference Enhancing patient safety and reducing errors in health care.
- Search function for numerous studies on adverse drug events, improvements and outcomes research.
Institute for Safe Medication Practices (ISMP)
- Independent, nonprofit organization that focuses on medication error reporting and reduction
- Medication alerts reported through a communication network to pharmacists and other professionals
- Encourages reporting of medication errors; supports interaction through questions and responses from pharmacy professionals
ISMP Medication Safety Alert!
ISMP publishes many articles available from the Web site at no charge. See "ISMP survey on perceptions of a nonpunitive culture produces some surprising results." (September 19, 2001)
http://www.ismp.org/MSAarticles/nonpunitive.html
Leapfrog Group
A leading group of Fortune 500 companies, and other large healthcare purchasers founded "The Leapfrog Group" by creating and committing to a common set of purchasing principles to drive leaps in patient safety.
The Leapfrog Group's goal is to mobilize employer purchasing power to initiate breakthrough improvements in the safety and overall value of healthcare to American consumers. It is a voluntary program aimed at mobilizing large purchasers to alert the healthcare industry that big leaps in patient safety and customer value will be recognized and rewarded with preferential use and other intensified market reinforcements.
The Leapfrog Group is supported by The Business Roundtable, a national association of Fortune 500 CEOs, The Robert Wood Johnson Foundation, Leapfrog members and others.
Massachusetts Coalition for the Prevention of Medical Errors (MCPME)
- Provides a brochure that may be downloaded as a pdf file: Your role in Safe Medication Use- a Guide for Patients
- Excellent seven-page summary document available in Word for download: Best Practice Recommendations to Reduce Medication Errors
MEDERRORS – Bridge Medical Inc.
Site devoted to providing information on medication errors and adverse drug events. Industry sponsored effort to assist in breakthrough technology to reduce medical errors. Site links to experts and resources, including:
- Library – comprehensive list of article summaries grouped by categories for ease in topic location; equipped with search function
- Incidence – one of the larger categories of literature focused on the frequency of occurrences
Medical Risk Management Associates, LLC
- Information from consulting company: Conducting a Cost-Effective Root Cause Analysis (RCA)
- Source for educational and training workshops on RCA. Espouses the process and methodology appropriate to the healthcare system, looking for system flaws and using performance improvement thinking
National Association of Boards of Pharmacy (NABP)
- Independent association to assist member boards in developing, implementing and enforcing uniform standards to protect public health
- Provides assistance in preventing fraudulent purchase of medications on-line
National Association for Healthcare Quality (NAHQ)
- Organization for healthcare quality professionals
- Links to the organization’s Journal for Healthcare Quality; for example, Redesigning a risk-management process for tracking injuries (February 1999)
National Coalition on Health Care (NCHC)
- Information, press releases and speeches related to initiatives such as A.C.T. for America’s Health.
- Report "Reducing medical errors and improving patient safety: success stories from the front lines of medicine." This report released, in February 2000, is available from NCHC through the Institute for Healthcare Improvement. Go to:
National Coordinating Council on Medication Error Reporting and Prevention (NCCMERP)
- The US Pharmacopoeia (see USP below) initiated this coordinating council of 19 national organizations to collaborate on identifying causes of medication errors and to promote safe use of medications
- Articles and commentaries provided
National Patient Safety Foundation (NPSF)
Major site on patient safety sponsored by the American Medical Association
- Numerous resources including links to all major organizations concerned with improving patient safety
- Major source of pertinent literature: books, journal articles, news stories
- Current research
http://www.ama-assn.org/ama/pub/category/5343.html
National Quality Forum (NQF),
National Forum on HealthCare Quality Measurement
The National Forum for Health Care Quality Measurement and Reporting is a not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. A shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and healthcare costs prompted leaders in the public and private sectors to create the National Quality Forum as a mechanism to bring about national change.
The Patient Safety Group
An on-line patient safety program to improve safety culture utilizing multimedia teaching tools, data collection and dissemination and sharing of results.
http://www.patientsafetygroup.org
PharmScope.com
- Online communication newsletter for pharmaceutical care management professionals
- Focuses on managed care arena but includes information, news, research pertinent to other interests
- Interactive support with peers, industry and information for purchasing decisions
US Pharmacopoeia (USP)
USP is a key organization long supporting and providing information on medication error reporting.
- USP is the major drug standards-setting organization and the creator of the Web-based MedMarx ™ system for facilitating medication error reporting and prevention. It includes an anonymous, secure database to encourage reporting of medication errors
- Provides numerous monographs on medications
Vaccine Adverse Event Reporting System (VAERS)
- FDA and CDC sponsored program for vaccine safety
- Post marketing safety surveillance program to collect information on adverse events that occur after administration of US licensed vaccines
http://www.fda.gov/cber/vaers/vaers.htm
Department of Veterans Affairs (VA)
National Center for Patient Safety (NCPS)
Provides patient safety self-learning lessons, such as Healthcare Failure Mode and Effects Analysis (HFMEA™), Root Cause Analysis (RCA) and Triage questions. View slide show online and/or download basic information from site.
http://www.va.gov/about_va/training.asp
Virtual Learning Center and Patient Safety
Provides dozens of self-learning modules involving patient safety, such as nonpunitive safety culture, wrong-site surgery, and restraints. View slide show online and/or download basic information from site.
http://www.va.gov/med/osp/cgi-bin/patientsafety_intronew_int.asp
VA Healthcare Network Upstate New York
- Site provides an extensive feature on the "VISN2" Network Policy: Integrated Patient Safety/Risk Management Program; information may be downloaded as pdf or Word files
- Includes program components such as incident reporting, flow charts for reportable events and root cause analysis for specific types of sentinel events