A Practical Tool to Learn From Defects in Patient Care

National Study on the Frequency, Types, Causes, and Consequences of Voluntarily Reported Emergency Department Medication Errors

“…More importantly, Ͻ 1% of errors were associated with a change or implementation of a procedure or policy, an action that may have a long-lasting opportunity to prevent medication errors. Research is needed to evaluate the extent to which efforts implemented in response to errors actually reduce the probability that the event will recur (25). Equally important, patients/family members were notified about medication errors Ͻ 3% of the time.…”

Framework for Patient Safety Research and Improvement

“…Details of this tool have been published previously. 66 More common tools that the Institute of Medicine has advocated for identifying hazards are incident reporting systems. 1 These systems are used at the local, hospital, and national levels (macroscopic), and they target broad or specific event types or clinical areas.…”

“…78 Efforts to evaluate the extent of risk reduction from other system changes are virtually nonexistent. 66 …”

Measurement of Quality and Assurance of Safety in the Critically Ill

“…23,24 Briefly, CUSP assesses safety culture, involves staff in identifying and mitigating safety hazards and investigating defects; 48 assigns a senior hospital leader to support unit-level safety activities; and provides tools to improve communication, teamwork, and other areas that pose safety hazards. 24,[48][49][50][51] Some other approaches to improving culture include operating room briefings; 52,53 executive walkrounds; 45,54 simulation; situation, background, assessment, and recommendation; 55 and culture debriefings. 56 Most of these tools are incorporated into the CUSP program.…”