Patient Safety Resources

When Things Go Wrong:  Responding to Adverse Events

A Consensus Statement of the Harvard Hospitals

Prepared by physicians, nurses, risk managers, and patients from the Harvard teaching hospitals, the document attempts to summarize the current thinking about the best practices to follow when a patient suffers injury from medical treatment. Its objectives are to provide a deeper understanding of the issues involved to help hospitals and caregivers develop more effective policies for managing patients and caregivers following injury. The concepts and principles are supported by he Harvard teaching hospitals.

Published on the Massachusetts Coalition for the Prevention of Medical Errors web site with permission.

• Click here to download a free PDF version
• Click here to purchase a bound copy for $15.00

Guideline for Patient Safety Programs in All Health Care Settings

This eight-page manual was developed by patient safety experts and provider associations to offer a simple description of patient safety programs for small health care settings of all types. The manual provides some general principles of patient safety, the basic elements of a patient safety program, and suggestions to get started or to enhance an existing program.

Click here to download a free PDF version

Patient and Family Advisory Council Audio Conference Calls

If you missed the Patient and Family Advisory Council Audio Call #1 on July 21, 2009, Call #2 on September 18, 2009, Call #3 on March 9, 2010 and Call #4 on June 15, 2010  or you participated and wish to hear the calls again:

A recording of the Audio Conference Calls on a CD format and the handout materials are now available through a link. What you will receive includes:

1. Audio Call Recording on CD
2. Presentations
3. MA Regulation for Patient and Family Advisory Councils
4. Hospital Self-Assessment Inventory
5. Template for September 30, 2009 Hospital Work Plan Approved by MA DPH
6. Road Map for Implementation of Patient and Family Advisory Councils
7. Toolkit

The pricing is:

• If you did not participate in these calls and want the Recorded Call, Handouts, and List Serve:
  • MA Coalition member = $150
  • Non-member = $250
• If you participated in the call and want the Recorded Call and Handouts on a CD:
  • Ma Coalition member = $25
  • Non-member = $50

To place your order, send an email to macoalition@macoalition.org

Anticoagulation Management October 28, 2009 and November 20, 2009 Audio Conference Calls

If you missed the Anticoagulation Audio Conference calls on October 28, 2009 and November 20, 2009 or you participated and wish to hear the calls again:

A recording of the Audio Conference Calls on a CD format and the handout materials are now available through a link. What you will receive includes:

• Audio Call Recording on CD
• Presentations and Handout Materials

“A practical, complete, and easy to understand guide to bridging patients on anticoagulants - highly recommended and essential presentation for all providers who care for patients on anticoagulation”, said Joseph J. Miaskiewicz, MD, North Shore Medical Center regarding the October 28th program on anticoagulation Bridging Strategies.

“I found the atrial fib call to be a terrific and concise summary - highly recommended for all clinicians who work with AF patients”, said Harvey Kowaloff, MD, MMM, Vice President of Medical Affairs, Jordan Hospital regarding the November 20th audio call.

“Both discussions were pertinent and informative”, said David K. Thompson, RPh, MS, Clinical Pharmacist, Jordan Hospital regarding the October 28th and November 20th audio calls.

Pricing for either the 10/28/09 or the 11/20/09 Audio Call Recordings:

• If you did not participate in the October and November calls and want the Recorded Calls, Handouts, and List Serve membership:
  • Physician practice = $35
  • MA Coalition hospitals = $75
  • Non-Coalition hospitals = $125
• If you participated in the calls and want the Recorded Call and Handouts on a CD:
  • Physician practice = $15
  • Ma Coalition hospitals = $15
  • Non-Coalitions = $25

Safe Handoffs at Change of Shift: Nurse Knowledge Exchange

The Joint Commission reports that approximately 70% of sentinel events are communication handoff issues. Handoffs are among the most hazardous situations in the inpatient care setting. This program will help you set up a nurse information exchange process for shift changes that helps to meet the National Patient Safety Goal 2E - Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.

This program will help hospitals and providers understand the successful four step change of shift handoff process used by nurses at Kaiser Permanente, known as Nurse Knowledge Exchange.

Patient Med List

You may update your Med List electronically.
Click here to download a free Patient Med List.

Reconciling Medications

Safe Practice Recommendations to Reconcile Medications
Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents
Out of print

Communicating Critical Test Results

Safe Practice Recommendations to Communicate Critical Test Results
Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents

Guide for Patients: “Your Role in Safe Medication Use”

English Online Version

Consumer Guide The Massachusetts Coalition for the Prevention of Medical Errors has developed a consumer guide that encourages patients to become "part of the health care team" along with their physicians, nurses, and pharmacists, to prevent medication mistakes. The guide was developed in conjunction with the Washington, D.C.-based Institute for Family-Centered Care and is based on input solicited from patients, families, and health care professionals. The brochure is also available in Spanish. For more information, contact: MA Coalition Phone:  781-262-6080 Email:  macoalition@macoalition.org

Spanish Online Version

Reporting Requirements

• Reporting Requirements Across Agencies
• The Coalition conducted an inventory of hospital reporting requirements across health care agencies. For each agency, the document identifies reportable incidents, incident specifics required when reporting, disclosable information, as well as confidentiality issues. The agencies presented include: Massachusetts Board of Registration in Medicine, Massachusetts Department of Public Health, Massachusetts Department of Mental Health, Massachusetts Office of the Chief Medical Examiner, JCAHO, CMS/LTC, and the FDA.
• This document was revised April 2004. It is a working document that is subject to change. If you have comments or updates, contact Effie Brickman at 781-262-6082 ext. 185 or macoalition@macoalition.org.

Restraints and Seclusion

• Best Practice Recommendations to Reduce Restaint & Seclusion Use - Definitions Included
• Improvement Workbook: includes articles, tools and other resources; available for purchase by contacting
  us at 781-262-6080 or macoalition@macoalition.org