Introduction: Monitoring hospital mortality rates is widely recommended. However, the number of preventable deaths remains uncertain with estimates in England ranging from 840 to 40 000 per year, these being derived from studies that identified adverse events but not whether events contributed to death or shortened life expectancy of those affected. Methods: Retrospective case record reviews of...

INTRODUCTION Monitoring hospital mortality rates is widely recommended. However, the number of preventable deaths remains uncertain with estimates in England ranging from 840 to 40 000 per year, these being derived from studies that identified adverse events but not whether events contributed to death or shortened life expectancy of those affected. METHODS Retrospective case record reviews of...

Tobacco use remains the leading cause of preventable death in this country and more needs to be done to reduce smoking rates. Harm reduction is one policy option. Smokers smoke for the nicotine, but die from the other toxins in cigarette smoke. Harm reduction in tobacco control aims to reduce the harm arising from nicotine use by shifting smokers, who are unable to quit, to using far less hazar...

Potential drug-drug interactions (PDDI) are a significant source of preventable drug-related harm. One contributing factor is that there is no standard way to represent PDDI knowledge claims and associated evidence in a computable form. The research we present in this paper addresses this problem by creating a new version of the Drug Interaction Knowledge Base, with scalable, interlinkable repo...

Medication errors are preventable events related to inappropriate medication use that could potentially result in patient harm. Here we present a patient encounter that has exemplified the importance of appropriate communication and the inevitable role of every individual in ensuring appropriate prescription medication use. Multidisciplinary efforts are required to ensure patient safety in toda...

Over the past two decades, the healthcare system has placed considerable attention on the concept of “failure to rescue” and the reduction of preventable harm in the hospital. Failure to rescue typically refers to the inability to recognize the early signs and symptoms of patient deterioration, or simply acting too late to prevent an in-hospital cardiopulmonary arrest. The concept of failure PA...

To cite: Bates DW, Sheikh A. BMJ Qual Saf 2015;24: 414–416. Large numbers of patients are injured annually by care that is intended to help them, and while many strides have been made in improving our understanding of patient safety considerations, it is not clear that this is translating into improvements in clinical outcomes. We now know that a small number of causes of harm appear to account...

Capitalizing on existing IT investments, INTEGRIS Health, a 15-hospital system in Oklahoma, is applying business process integration (BPI) methodology and technology to leverage legacy systems and staff resources. The resulting project uses manual (human) and system tasks to compare real-time information across systems to eliminate preventable adverse drug events caused by medication ordering e...