Medical errors rank behind heart disease and cancer as the third leading cause of death in the U.S., Johns Hopkins researchers say. ... Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year frommedical errors.May 3, 2016
10 percent of U.S. deaths are due to preventable medical mistakes.
SURGICAL ERRORS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Common Surgical Errors: They can Change Your Life
Patient Safety in the Surgical Environment - ACOG Committee Opinion 464
HOW TO AVOID SURGICAL ERRORS - OR /Today 2016
Speak Up: Preventing Surgical Errors - Joint Commission
Clinician Information - SAFR Guidelines
MEDICATION ERRORS
Specifically, a medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
MedlinePlus - National Institutes of Health
Institute for Safe Medication Practices
DIAGNOSTIC ERRORS
Diagnostic Errors - AHRQ
​Diagnostic Errors - World Health Organization 2016
Reducing Diagnostic Errors - Health Leaders October 2016
National Guideline Clearinghouse
HOSPITAL ACQUIRED INFECTION
Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common types are bloodstream infection (BSI), pneumonia (eg, ventilator-associated pneumonia [VAP]), urinary tract infection (UTI), and surgical site infection (SSI).
Clinical Advisor - Hospital Associated Infections
Clinical Advisor - Nosocomial Infections
Healthcare-associated Infections - CDC
Committee to Reduce Infection Deaths
How Your Hospital Can Make You Sick - Consumer Reports 2015
Guidelines Issued on Contact Precautions for MRSA - The Society for Healthcare Epidemiology of America has issued guidelines on how long contact precautions in acute-care hospitals should persist for numerous drug-resistant infections and Clostridium difficile.
HANDWASHING
The CDC has identified handwashing as the single most important means of preventing the spread of infection.5
HANDOFFS - HANDOVERS - SHIFT REPORT
The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient.
Ineffective hand-off communication is recognized as a critical patient safety problem in health care; in fact, an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.
Communication failures linked to 1,744 deaths in five years, US malpractice study finds - STAT February 2016
Handoff Communications - Joint Commission Center for Transforming Healthcare
The Joint Commission requires that the “process for hand-off communication provides for the opportunity for discussion between the giver and the receiver of patient information”
Handoffs and Signouts - AHRQ Patient Safety Network
I - Pass. Better Handoffs. Safer Care - Boston Children's Hospital
Communications Strategies for Patient Handoffs - ACOG Committee Opinion 517
Warm Handoff : transfer of care between two members of the health care team, where the handoff occurs in front of the patient and family. - AHRQ
10 Patient Handoff Communications Tools - Beckers 2014
Bedside Reporting at Shift Change - Press Ganey
HOSPITAL ACQUIRED INJURIES
Hospital-acquired injuries are falls and other traumatic injuries (broken or dislocated bones, crushing injuries, or burns) that occur while a patient is in the hospital.
FALLS
Researchers estimate that more than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries.
Preventing falls and fall-related injuries in health care facilities - The Joint Commission, 2015
PRESSURE INJURIES (formerly PRESSURE ULCERS)
Pressure injuries (previously referred to as pressure ulcers) can occur for a variety of reasons, and can lead to pain, decreased quality of life, ​psychological stress, loss of work, and even death
Preventing Hospital Acquired Pressure Ulcers/Injuries - Health Research & Educational Trust (2017, April)
Ready, Set Go - Know Your Risks : Pressure Injuries - ECRI Institute
Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse, or dependency (addiction).
Drug Addiction in Health Care Professionals - Drug Enforcement Administration
New Law Requires Reporting of Healthcare Workers Who Fail or Refuse Drug Tests - Tennessee
Recognizing Impairment in the Workplace for Florida Nurses - Wild Iris Online Continuing Education Course
Diversion: A Quiet Threat in the Healthcare Setting - American College of Emergency Physicians
Workplace Impairment of the Health Care Professional - AMA policies and JCAHO standards
ASHP Guidelines on Preventing Diversion of Controlled Substances
Drug diversion and impaired healthcare workers - Joint Commission April 2019