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Medical Errors & Patient Safety

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The very critical issues of medical errors and patient safety have received a great deal of attention. In November 1999, the Institute of Medicine (IOM) released a report estimating that as many as 98,000 patients die as the result of medical errors in hospitals each year.

A major Federal initiative has been launched to reduce medical errors and improve patient safety in federally funded health care programs, and by example and partnership, in the private sector.

Online Journals

AHRQ Patient Safety Network
Web M&M: Morbidity & Mortality Rounds Online

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Documents

Five Steps to Safer Health Care
10 Patient Safety Tips for Hospitals (PDF File, 140 KB)
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
20 Tips to Help Prevent Medical Errors in Children
30 Safe Practices for Better Health Care: Fact Sheet
Advances in Patient Safety: From Research to Implementation
AHRQ Partnerships in Implementing Patient Safety
AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk: Interim Report to the Senate Committee on Appropriations
AHRQ Patient Safety Tools and Resources
AHRQ's Programs and Projects on Quality and Safety, by State
Ambulatory Safety and Quality Program: Health IT Portfolio
Automated Telephone Reminders
Be Prepared for Medical Appointments
Becoming a High Reliability Organization: Operational Advice for Hospital LeadersNew!
Closing the Quality Gap: A Critical Analysis of Strategies
Closing the Quality Gap: Diabetes Care Strategies
Closing the Quality Gap: Hypertension Care Strategies
Consumer Financial Incentives: A Decision Guide for Purchasers
Developing a Community-Based Patient Safety Advisory CouncilNew!
DoD Medical Team Training Programs: An Independent Case Study Analysis
The Effect of Health Care Working Conditions on Patient Safety
Empirical Evaluation of the Association Between Methodological Shortcomings and Estimates of Adverse Events: Technical Review
High Reliability Organization (HRO) Strategy
The Hospital Built Environment: What Role Might Funders of Health Services Research Play?
Hospital Survey on Patient Safety Culture
   Year 2 Comparative Database Submission Information
   2008 Comparative Database ReportNew!
   2007 Comparative Database Report
   Third Technical Assistance Conference Call
How to Create a Pill CardNew!
Impact of Working Conditions on Patient Safety
Improving Health Care Quality: Fact Sheet
Improving Patient Safety Through Simulation Research
Is Our Pharmacy Meeting Patients' Needs?
It's Your Health: Use Your Medications Safely
Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Summary, Evidence Report
Medical Errors: The Scope of the Problem
Medical Teamwork and Patient Safety: The Evidence-based Relation
Medication Errors Found To Be Common in Pediatric Inpatients
Mistake-Proofing the Design of Health Care Processes
Monitoring and Evaluating Medicaid Fee-for-Service Care Management Programs: User's Guide
National Survey on Consumer Experiences With Patient Safety and Quality
New Research Projects Awarded To Improve Patient Safety
Partnerships for Quality: Fact Sheet
Purchaser-Provider Synergies Overview
Patient Safety: Achieving a New Standard for Care: Institute of Medicine report on health care data standards
Patient Safety Challenge Grants
Patient Safety Improvement Corps
Patient Safety and Quality: An Evidence-Based Handbook for NursesNew!
Patient Safety and Quality Improvement Act of 2005
Patient Safety Organizations: Web SiteNew!
Patient Safety Research Highlights: Program Brief
Patient Safety Tools: Improving Safety at the Point of Care
Priority Areas for National Action: Transforming Health Care Quality
Problems and Prevention: Chest Tube Insertion
Reducing and Preventing Adverse Hospital Costs
Reducing Medical Errors in Health Care: Fact Sheet
Safe Practices for Better Healthcare: Summary: National Quality Forum Consensus Report
Strategies to Improve Communication Between Pharmacy Staff and Patients
TeamSTEPPSUpdated!
To Err is Human: Building a Safer Health System: Institute of Medicine report on medical errors
Toolkit for Redesign in Health Care: Final Report
Tools, Methods, and Techniques for Improving Patient SafetyNew!
Transforming Hospitals: Designing for Safety and Quality
   DVD Available
Ways You Can Help Your Family Prevent Medical Errors!
Web Chat Transcript: Patient Safety Research
AHRQ Web M&M: Fact Sheet

Patient Safety E-newsletter Archives

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Patient Safety Task Force

Fact Sheet: Patient Safety Task Force
Proposal for New Federal Patient Safety Data System
Fact Sheet: Patient Safety Reporting Systems and Research in HHS
Final Agenda: National Summit on Patient Safety Data
Participant List: National Summit on Patient Safety Data
Web Cast: National Summit on Patient Safety Data

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Conferences and Workshops

AHRQ's Quality Challenge Summit
Agenda for Research in Ambulatory Patient Safety: Conference Synthesis
Beyond State Reporting: Medical Errors and Patient Safety Issues
Building the Business Case for Patient Safety: Audio Tapes Available
Can You Minimize Health Care Costs by Improving Patient Safety?
   Web-Assisted Teleconference Proceedings
How Safe Is Our Healthcare System? What States Can Do To Improve Patient Safety and Reduce Medical Errors
Improved Patient Safety: Sharing Issues, Successes, and Challenges Across States: Workshop Brief
Improving Patient Safety In Rural Hospitals: A Workshop With Wisconsin Health Care Leaders
Making the Health Care System Safer: Second Annual Patient Safety Research Conference
Making the Health Care System Safer: Third Annual Patient Safety Research Conference
Partnerships in Implementing Patient Safety: Technical Assistance Conference Call Summary

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Speeches and Statements on Medical Errors

Date   Title
9/27/06 Remaking American Medicine
9/25/06 The Culture of Safety
10/25/05 Health Information Technology, Quality of Care, and Evidence-based Medicine: An Interlinked Triad
9/9/05 Health Information Technology and the "Quality Movement"
6/8/05 Quality Is the Goal for Patient Safety and Health IT: Carolyn Clancy, M.D.
2/22/00 Remarks by President Clinton on Medical Errors
2/19/00 White House Actions to Improve Patient Safety
1/20/00 The Best Offense Is a Good Defense Against Medical Errors: John M. Eisenberg, M.D.
12/7/99 Remarks by President Clinton on Health Care

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Congressional Hearings

Date   Title
6/9/05 Testimony on Patient Safety Activities at HHS: Carolyn Clancy, M.D.
3/19/04 Testimony on Health Care Quality Initiatives: Carolyn Clancy, M.D.
6/11/03 Testimony on Patient Safety: Carolyn Clancy, M.D.
5/24/01 Testimony to Senate HELP Committee Hearing on Medical Errors: Secretary Thompson
2/22/00 Response of the Quality Interagency Coordination (QuIC) Task Force (Watch Video)
2/16/00 Medical Errors: Federal and State Reforms, Montpelier, VT
2/9/00 Fiscal Year 2001 Budget Request
12/13/99 Statement on Medical Errors: John M. Eisenberg, M.D.

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