In 2005, our organization set a goal of zero preventable deaths by 2010--notionally a sound goal but extremely challenging to measure, monitor and evaluate. The development of an interdisciplinary Death and Adverse Event Review process has provided a measure and framework for action to decrease adverse events (AEs) that cause harm. Death and Adverse Event Review is a formal process in which tra...

There is little agreement in the literature as to what types of patient safety events (PSEs) should be the focus for learning, change and improvement, and we lack clear and universally accepted definitions of error. In particular, the way front-line providers or managers understand and categorize different types of errors, adverse events and near misses and the kinds of events this audience bel...

OBJECTIVE Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric ...

BACKGROUND Preventable medical errors continue to be a major cause of death in the USA and throughout the world. Many patients have written about their experiences on websites and in published books. METHODS As patients and family members who have experienced medical harm, we have created a nationwide voluntary survey in order to more broadly and systematically capture the perspective of pati...

BACKGROUND Adverse events are considered a major international problem related to the performance of health systems. Evaluating the occurrence of adverse events involves, as any other outcome measure, determining the extent to which the observed differences can be attributed to the patient's risk factors or to variations in the treatment process, and this in turn highlights the importance of me...

Polypharmacy is a common and potentially preventable contributor to recurring emergency room visits, hospitalization, morbidity, mortality. Its consequences are magnified in older adults due the age-related decrease functional physiologic reserves, increased blood-brain barrier permeability, altered drug metabolism, among others. In this article, we describe case of polypharmacy septuagenarian ...

Introduction: Health systems currently present a great degree of complexity, which provides risks to patients related healthcare, and the possibility incidents with or without harm. Patient safety culture highlights need investigate, analyze, mitigate reduce patient. Medication errors have high potential do harm in pediatric hospital routines most them are preventable. The objective this study ...

BACKGROUND Adverse drug events (ADEs) are the most common cause of injury to hospitalized patients and are often preventable. Medication errors resulting in preventable ADEs most commonly occur at the prescribing stage. OBJECTIVES To describe the epidemiology of medication prescribing errors averted by pharmacists and to assess the likelihood that these errors would be prevented by implementi...

BACKGROUND Delirium is common in older hospitalized patients, and is associated with negative consequences for the patients, next of kin, healthcare professionals and healthcare costs. It is important to understand its clinical features, as almost 40% of all cases in hospitals may be preventable. Yet, delirium in hospitalized patients is often unrecognized and untreated. Few studies describe th...

BACKGROUND Venous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of VTE prophylaxis in hospitals, with varying degrees of success. We reviewed key articles to assess the efficacy of different types of interventions to improve prescription of VTE...