IMPROVEMENT IN HEALTH CARE QUALITY AND SAFETY CAN be notable when measurement criteria are clear, evidence is strong, and policy and interventions are focused. Despite this potential, progress in reducing patient harm in hospitals has been slow. In an effort to catalyze progress, the Department of Health and Human Services (HHS) is funding a national program, Partnership for Patients (P4P), wit...

OBJECTIVE The objectives of this study are to determine the prevalence and preventability of adverse events requiring an unplanned higher level of care, defined as an unplanned transfer to the ICU or an in-hospital medical emergency team intervention, and to assess the type and the level of harm of each adverse event. DESIGN A three-stage retrospective review process of screening, record revi...

BACKGROUND Understanding the nature and causes of medical adverse events may help their prevention. This systematic review explores the types, risk factors, and likely causes of preventable adverse events in the hospital sector. METHODS MEDLINE (1970-2008), EMBASE, CINAHL (1970-2005) and the reference lists were used to identify the studies and a structured narrative method used to synthesise...

InSite is North Americas first supervised injection site and a landmark public heath initiative operating in Vancouver since 2003. The program is a vital component of that cities internationally recognized harm reduction approach to its serious problems with drugs, crime, homelessness and AIDS. InSite currently operates under a waiver of Federal rules that allow it to provide services as a rese...

PURPOSE Cancer treatments are complex, involving multiple clinicians, toxic therapies, and uncertain outcomes. Consequently, patients are vulnerable when breakdowns in care occur. This study explored cancer patients' perceptions of preventable, harmful events; the impact of these events; and interactions with clinicians after such events. PATIENTS AND METHODS In-depth telephone interviews wer...

Errors in the medicines management process represent an important source of iatrogenic harm in primary care. Most errors result from underlying systems-based problems that are amenable to intervention and potentially preventable. In this paper, we seek to identify the frequency of medication-related morbidity in primary care, understand the underlying systemic reasons that increase risk of medi...

Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that “first, do no harm” has been the ethical watchword throughout the history of medicine, nursing, and pharmacy. In recent years, we have become increasingly aware of the magnitude of our failure to successfully live up to this ethical imperative. We have also become increasingly aware of...

Protecting patients from harm is one of the most important things health professionals can do for their patients. However, an estimated 1 in 10 patients are harmed while receiving hospital care in high-income countries,1 and studies suggest that the rates of harm are higher in lowand middleincome countries.2 The World Health Organization (WHO) describes safety as a key dimension of quality heal...