Patient Safety Web Sites
General Topics and Tools
- EthnoMed is an invaluable resource: this site contains information about the cultural beliefs, medical issues, and related topics pertinent to the health care of immigrants, many of whom are refugees.
- Quality improvement for patient safety: project-level versus program-level learning. Rivard PE et al, Agency for Healthcare Research and Quality. Health Care Manage Rev. 2012 Jan 20; [Epub ahead of print]. This study was conducted in four Veterans Affairs hospitals, aimed at understanding factors behind the success of quality improvement programs and found that program-level learning was essential to developing approaches that yielded organizational improvement in patient safety.
- AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety
- AHRQ: Toolkit for Establishing a Community-Based Safety Advisory Council
- AHRQ Innovations Exchange
- AHRQ Patient Safety Organizations
- AHRQ Patient Safety Primers
- Common Formats for Collecting and Reporting Patient Safety Information
- The National Center for Patient Safety (Veterans Affairs)
- The Joint Commission: National Patient Safety Goals
- The Joint Commission’s 2007 Report on Improving America’s Hospitals
- Institute of Medicine’s Health Care Quality Initiative
- The Institute for Healthcare Improvement
- World Health Organization Patient Safety Programs
- Duke University Patient Safety/QI modules
- Society of Hospital Medicine’s Care Transitions for Older Adults Resource Room
- Reducing Health Care Hazards: Lessons from the Commercial Aviation Safety Team
- National Quality Forum report: The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care [.pdf]
- Washington State Department of Health’s Adverse Events website
- Checklists to Improve Patient Safety,Health Research and Educational Trust
- TeamSTEPPS® has multiple versions for primary care, long-term care, and other settings. *NEW*
- Silence Kills Study
- Disruptive Behaviors
- Code of Conduct
- American College of Physician Executives journal – special issue on disruptive behavior
- AHRQ Patient Safety Primer on Disruptive and Unprofessional Behavior
- Strategies for Improving Patient Safety: Linking Task Type to Error Type, Mattox EA, National Patient Safety Foundation, Crit Care Nurse. 2012(Feb); 32(1):52–60, 78. This article uses case examples to illustrate circumstances in which different types of errors (as defined in James Reason’s classification scheme) may occur in clinical practice. The author suggests that understanding the relationship between particular tasks and types of errors can improve health care providers’ ability to anticipate and protect against these mistakes.
- Nurturing a Culture of Patient Safety and Achieving Lower Malpractice Risk through Disclosure: Lessons Learned and Future Directions, Boothman RC et al, National Patient Safety Foundation, Front Health Serv Manage. 2012(Spring); 28(3):13–28. This article describes the University of Michigan’s experience in instituting a new approach to medical injuries and malpractice claims management, centering on transparent disclosure, apology, and offers of compensation where appropriate for patients injured as a result of errors in their care. Contrary to concerns that such an approach would lead to increased malpractice liability, implementation of the program was associated with a reduction in the number of claims and related costs.
- Factors Associated with Disclosure of Medical Errors by Housestaff, Kronman AC et al, National Patient Safety Foundation, BMJ Qual Saf. 2012(Apr); 21(4):271–278. This study examined correlates of error disclosure among medical trainees, seeking to determine whether characteristics of individuals and of their learning environment influenced the likelihood of disclosure and apology for error. In a survey of 99 medical and surgical residents at an academic medical center, the authors found that only 17% of respondents reported disclosing their “worst medical error” to the patients and families involved. A number of aspects of organizational culture as well as individual factors showed correlations with error disclosure. The authors conclude that measurement of organizational safety culture may provide insights into the relationship between the clinical training environment and response to medical error.
- How to Develop a Second Victim Support Program: A Toolkit for Health Care Organizations, Pratt S et al, National Patient Safety Foundation, Jt Comm J Qual Patient Saf. 2012(May); 38(5):235–24. Growing recognition of the negative emotional impact of adverse events on care providers has led to calls for health care organizations to establish formal clinician support systems as a component of institutional incident response. This article describes how, in an effort to provide guidance for such initiatives, a group of patient safety experts created a set of evidence-based tools designed to help institutions develop and implement programs to support clinicians involved in adverse events. The authors describe the development and contents of the toolkit and discuss possibilities for its application and further refinement.
- Medical Errors Reported by French General Practitioners in Training: Results of a Survey and Individual Interviews, Venus E et al, National Patient Safety Foundation, BMJ Qual Saf. 2012(Apr); 21(4):279–286. This study used a survey and interviews to examine medical errors among general practitioner interns at a French university, seeking to provide insight into the emotional impact of errors on trainees and how errors were addressed within the training curriculum. Findings suggested that involvement in an error had a strong emotional impact on trainees, often leading to persistent feelings of guilt and self-doubt, and that these difficulties could be exacerbated by a lack of institutional support for dealing with errors. Recommendations for improvement include promoting opportunities for constructive discussion of medical errors and incorporating formal education on errors in the training curriculum.
- Catching and Correcting Near Misses: The Collective Vigilance and Individual Accountability Trade-Off, Jeffs LP et al, National Patient Safety Foundation, J Interprof Care. 2012(Mar); 26(2):121–126. This qualitative study explored how health care professionals conceptualize and deal with near-miss incidents in the course of clinical practice, focusing specifically on the role of interprofessional collaboration in shaping clinicians’ attitudes and behaviors. The authors used a grounded theory approach involving interviews with 24 clinicians and administrators at a Canadian teaching hospital. A notable finding was that “collective vigilance,” although useful as a means of intercepting errors and preventing patient harm, could also serve to undermine safety by reducing providers’ sense of individual responsibility in preventing error.
- Medication Errors during Medical Emergencies in a Large, Tertiary Care, Academic Medical Center, Gokhman R et al, National Patient Safety Foundation, Resuscitation. 2012(Apr); 83(4):482–487. This study sought to describe the frequency and characteristics of medication errors occurring during care provided by Medical Emergency Teams (METs) at an academic medical center. In a prospective analysis of 50 patients who received MET care, the authors identified 296 errors, of which nearly two-thirds involved improper aseptic technique. Errors not related to aseptic technique included mistakes in prescribing, administration, labeling, dose, and drug preparation. The authors conclude that medication errors during MET care are common and have the capacity to cause significant harm to patients, and they discuss possible strategies for improving medication safety in this setting.
- Open Disclosure of Adverse Events: Transparency and Safety in Health Care, Eaves-Leanos A et al, National Patient Safety Foundation, Surg Clin North Am. 2012(Feb); 92(1):163–177. This article articulates the ethical, legal, and professional arguments for transparent disclosure of adverse events and illustrates how the authors’ institution, a Veterans Health Administration medical center, has developed and implemented an open disclosure approach based on these principles.
- Alleviating “Second Victim” Syndrome- How We Should Handle Patient Harm. Carolyn M. Clancy, MD, Agency for Healthcare Quality and Research. J Nurs Care Qual. 2012; 27:1-5. This commentary discusses second victims and describes how blame-free reporting and disclosure can minimize harm.
- Guilty, Afraid, and Alone — Struggling with Medical Error. Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-1683.
- Coming Clean on Medical Mistakes Talaga T, Cribb R. Toronto Star. March 19, 2007.
- Disclosing Harmful Medical Errors to Patients Gallagher TH, Studdert D, Levinson W N Engl J Med 2007;356:2713-9
- A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical ErrorGallagher THJAMA 2009;302(6):669-677
Hand Hygiene and Infection Control
- Optimisation of Infection Prevention and Control in Acute Health Care by Use of Behaviour Change: A Systematic Review, Edwards R et al, National Patient Safety Foundation, Lancet Infect Dis. 2012(Apr); 12(4):318–329. This study used a systematic review of literature to examine evidence concerning the effectiveness of behavioral interventions designed to improve health care workers’ adherence to infection control practices. The authors present findings from an analysis of 21 published studies and offer recommendations based on their findings for the design of further research in this area.
- Implementing Strategic Bundles for Infection Prevention and Management, Kaier K et al, National Patient Safety Foundation, Infection. 2012(Apr); 40(2):225–228. This article highlights the design and objectives of the IMPLEMENT project, an infection prevention initiative being carried out by a group of hospitals in several European countries. The project focuses on advancing scientific understanding of the implementation of “bundled” practices for prevention and control of health care–associated infections
- Association for Professionals in Infection Control and Epidemiology
- The Society for Healthcare Epidemiology in America
- Infectious Diseases Society of America
- Save Lives: Clean Your Hands
- AHRQ/Department of DefenseTeamSTEPPS Limited English Proficiency module and Hospital Guide. Copies of the module CD are available by sending an e-mail to AHRQPubs@ahrq.hhs.gov.
- Health Literacy and Cultural Competency
- AMA Foundation’s Health Literacy Kit and Health Literacy Video
- Health Literacy Resources (compiled by Gail Nielsen)
- Health Literacy Teleconference Presentation by Gail Nielsen [2MB .pdf, September 2008]
- Michigan Cancer Consortium’s Booklet on Prostate Cancer Decision-Making
- National Institute for Literacy’s Health Literacy Discussion List
- Resources for Tear Sheets/Tear Pads: KramesPritchell & Hull
- Rhode Island Health Literacy Project
- AHRQ’s Pharmacy Health Literacy Center
- About the CAHPS® Item Set for Addressing Health Literacy
Human factors engineering and safety resources
Laboratory Quality and Safety
Patient/consumer-oriented materials and information
- The Choosing Wisely campaign
- What Do Patients and Relatives Know about Problems and Failures in Care?, Iedema R et al, National Patient Safety Foundation, BMJ Qual Saf. 2012(Mar); 21(3):198–205. This study explored patients’ knowledge and experiences of safety problems in health care, using data from 100 interviews conducted with patients and family members in New South Wales, Victoria, and Queensland, Australia. The authors found that study participants demonstrated insights into safety risks and incidents in their care and identified opportunities for improvement, but that they struggled to communicate about these issues with care providers, often feeling that their concerns went unheard.
- Arizona CERT’s Guidelines for Safe Medication Use
- Washington State Medical Association
- Food and Drug Administration
- Agency for Healthcare Research and Quality
- Washington State Department of Health
- SafeMedication.com (ASHP)
- Partnership for Patient Safety
- Washington State Hospital Association
- National Quality Forum’s Guidelines for Consumer-Focus Public Reporting [.pdf]
- AHRQ: Talking to Consumers about Health Care Quality
- AHRQ: Questions are the Answer campaign
- Consumers Advancing Patient Safety
- Washington Poison Center’s “Prevention and Treatment Guide – Medications”
- Washington Health Foundation’s “My Health Home Bookshelf”
- Institue for Patient and Family Centered Care *NEW*
Patient Safety Culture
- Is Patient Safety Improving? National Trends in Patient Safety Indicators: 1998–2007, Downey JR et al, National Patient Safety Foundation, Health Serv Res. 2012(Feb); 47(1 Pt 2): 414–430. This study sought to assess hospital patient safety improvement over time through an analysis using the Agency for Healthcare Research and Quality patient safety indicators (PSIs). The analysis examined national data on more than 69 million hospitalizations to assess changes in rates of PSI events during a 10-year period. Results showed that of the 14 PSIs with statistically significant trends, 7 showed increasing rates and 7 showed decreasing rates during the period examined. The authors suggest that such findings could help guide improvement efforts by identifying targets for intervention as well as successes for potential replication.
- The Effects of Aviation Error Management Training on Perioperative Safety Attitudes, LaPoint JL, National Patient Safety Foundation, International Journal of Business and Social Science. 2012;3(2):77–90. This study evaluated the impact of crew resource management training on teamwork- and safety-related attitudes among operating room personnel at a major US hospital. Results showed positive changes in a variety of safety-related attitudes following the training, suggesting that the intervention had a favorable impact on organizational safety culture.
- Patient safety: what about the patient? Vincent CA and Coulter A, Agency for Healthcare Research and Quality. Qual Saf Health Care. 2002;11:76-80. This perspective highlights the need for increased patient involvement in the patient safety movement. The authors emphasize that neither the patient’s role in preventing errors nor the impact of these errors on patients and their families has been adequately addressed. The authors outline the patient’s role in increasing diagnostic accuracy, determining appropriate treatment, choosing experienced providers, ensuring effective treatment and disease management, and monitoring adverse events. In addition, the authors explain that psychological injury from medical errors must be acknowledged and dealt with appropriately, including honest disclosure, apology, continued support, and plans for preventing future events.
- An examination of opportunities for the active patient in improving patient safety Davis RE et al, Agency for Healthcare Research and Quality. J Patient Saf. 2012 Jan 17; [Epub ahead of print]. The Joint Commission established engagement of patients in safety as a National Patient Safety Goal in 2007. Organizations have made various efforts to include patients in safety programs. This review uses patients undergoing surgery to establish a framework for the roles patients can play in ensuring their own safety. In this framework, safety-related behaviors can be classified according to the type of error being prevented, the specific action the patient must undertake (asking questions), and the characteristics of the action. The article also discusses the barriers that can limit patient involvement.
- Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions Taylor JA et al, Agency for Healthcare Quality and Research. BMJ Qual Saf. 2012;21:101-111. The study results showed that hospital units with poor safety climate had an increased risk of preventable adverse events for patients and an increased risk of injuries among nurses, indicating a close link between safety culture and nurses’ working conditions.
- AHRQ survey
- AHRQ’s Preliminary Report presents results from its updated Hospital Survey on Patient Safety Culture.
- AHRQ Survey to Assess Medical Office Safety Culture
- Leapfrog Never Events Fact Sheet
- On-line Patient Safety Climate Survey: Tool Development and Lessons Learned Advances in Patient Safety: From Research to Implementation Volumes 4, AHRQ Publication Nos. 050021 (1-4).
- Safety Attitudes Questionnaire and Safety Climate Survey University of Texas, Houston The Safety Climate Survey: Psychometric and Benchmarking Properties Technical Report 03-03 J B Sexton and E J Thomas
Patient Safety Curriculum
- Variations in surgical outcomes associated with hospital compliance with safety practices Brooke BS et al, Agency for Healthcare Quality and Research. Surgery. 2012 Jan 17; [Epub ahead of print].
This study looked at nearly 80,000 Medicare patients to determine whether implementation of the National Quality Forum’s (NQF) Safe Practices for Better Healthcare was associated with more effective treatment of postoperative complications. The results showed that hospitals that had fully implemented the safe practices had a lower incidence of failure to rescue and lower overall postoperative mortality.
Please visit the SCOAP website to access resources related to surgical safety.
- World Health Organization
- Australian Council for Safety and Quality in Health Care
- Australian Patient Safety Foundation
- Canadian Patient Safety Institute
- National Patient Safety Agency (UK)
- Agency for Healthcare Research and Quality (AHRQ)
- National Patient Safety Foundation
- VA National Center for Patient Safety
- The Joint Commission
- Ann Arbor VA Medical Center/ University of Michigan Health System – Patient Safety Enhancement Program
- Hospital Council of Northern and Central California
- The Betsy Lehman Center for Patient Safety and Medical Error Reduction
- California Hospital Patient Safety Organization
- Connecticut Center for Patient Safety
- Florida Patient Safety Corporation
- Maryland Patient Safety Center
- Massachusetts Coalition for the Prevention of Medical Errors
- Minnesota Alliance for Patient Safety
- Missouri Center for Patient Safety
- Ohio Patient Safety Institute
- Oregon Patient Safety Commission
- Pennsylvania Patient Safety Authority
- Strategic Alliance for Error Reduction (SAFER) Healthcare California
- Texas Center for Quality and Patient Safety
Second Victim Resources
* Won’t you help us by taking this brief Second Victim Survey? If you have filled it out previously, we still want to hear from you with any updates.
“A health care provider involved in an unanticipated adverse patient event, medical error, and/or a patient related–injury who become victimized in the sense that the provider is traumatized by the event. Frequently second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patient, second guessing their clinical skills and knowledge base.” (Seys et al., 2012)
The speakers at the closing session of the 2012 Washington Patient Safety Coalition’s annual conference were Chris Jerry and Eric Cropp, who spoke together about a terrible event that occurred several years ago and its effects on both their lives: Chris’ young daughter died as the result of a medication error for which Eric (as the supervising pharmacist) was held responsible. During the discussion several attendees described their organizations’ interest in, and/or work pertaining to, supporting Second Victims more effectively.
Over the past year the Coalition has facilitated meetings of anyone interested in learning from others and sharing this work. One of the products of those discussions is a summary of Second Victim work underway at various Northwest organizations. The resource document is available via the link below and will be updated on a regular basis. For more information about the workgroup or to contribute information about your SV program, please contact Miriam Marcus-Smith, WPSC Program Director, at (206) 682-2811 ext. 11 or firstname.lastname@example.org.
Annotated Resource List
- Denham, C.R. (2007). Trust: The 5 Rights of the Second Victim. Patient Safety, 107-118. This article suggests that as part of a just culture, there exists 5 rights of a caregiver, and recommends investing in the systems and tools needed to adequately respond to adverse events so that the rights of a caregiver can be met.
- Hu, Y.-Y., Fix, M.L., Hevelone, N.D., Lipitz, S.R., Greenberg, C.C., Weissman, J.S., et al. (2012). Physicians’ Needs in Coping with Emotional Stressors: The Case for Peer Support. The Journal of the American Medical Association: Surgery, 212-217. Findings and recommendations from an evidence-based study to address physician distress after an adverse patient or personal event. Researchers recommend peer support over any other type of service as being most effective.
- Physicians Insurance. (2012). Ensuring 360° Compassion: The Value of Provider Support Programs. Seattle: Physicians Insurance.This document describes a second victim and the associated costs of failing to address the needs of a caregiver after an adverse event.
- SafetyLeaders.org. (2011). A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing. Webinar transcript.Webinar transcript of patient safety advocates Christopher Jerry and Eric Cropp’s first meeting. The webinar includes a history/account concerning an error on the part of pharmacist Eric Cropp that led to the death of Christopher Jerry’s two-year-old daughter, Emily Jerry.
- Scott, S. D., Hirschinger, L.E., Cox, K.R., McCoig, M., Hahn-Cover, K., Epperly, K.M., et al. (2010). Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. The Joint Commission Journal on Quality and Patient Safety, 233-240. Article describes the deployment efforts of an institutional (University of Missouri Health Care) rapid response system (RRS) for second victims. Based on their experience, the authors believe that the necessary components of a second victim RRS exist within most health care organizations.
- Seys, D., Wu, A. W., Van Gerven, E., Vleugals, A., Euwema, M., Panella, M., et al. (2012). Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions, 12.A review of existing literature regarding the impact of adverse events on second victims, a call for increased awareness, and the need to offer support mechanisms to aid second victims involved in unanticipated events.
- Seys, D., Scott, S., Wu, A.W., Van Gerven, E., Vleugals, A., Euwema, M., Panella, M., et al. (2012). Supporting Involved Health Care Professionals (second victims) Following and Adverse Health Event: A Literature Review. International Journal of Nursing Studies, 678-687.This study reviewed existing literature in order to identify supportive interventional strategies for second victims. It concluded that second victim support is needed to improve the quality of care for patients.
- http://nextlevel.gehealthcare.com/videos/webcasts/the-second-victim.php Dr. Albert Wu, practicing internist and professor at Johns Hopkins, and James (Jim) Conway, adjunct faculty at Harvard School of Public Health and senior Fellow with the Institute for Healthcare Improvement, discuss issues regarding second victims, and what is needed to start a second victim program.
- MITSS (Medically Induced Trauma Support Services) Tools Tools and other resources to aid with second victim/provider support programs. In addition to providers support, MITSS also includes help for families and patients.
- University of Missouri A second victim program that provides their tools to aid other programs/efforts.