In July 2001, a 6-year-old boy died in a tragic MRI accident at the Westchester Medical Center in New York state.

The wave of hospital consolidations in the 1990s introduced many healthcare leaders to the complex issues that challenge the management of larger systems (Luke et al.,1995).

November / December 2007 Editor’s Notebook Common Themes By Susan Carr, Editor I spent half of my workdays in October attending healthcare conferences: the 24th annual conference of the International Society for Quality in Health Care (ISQua), in Boston; the Annual Conference & Exhibition of the American Society for Healthcare Risk Management (ASHRM), in Chicago; … Continued

In a series of articles in Patient Safety and Quality Healthcare, we will describe the replicable process we have used at Hunterdon Medical Center to improve patient safety and create high reliability throughout the system, focusing first on maternity care.

Increasing emphasis on patient safety has led healthcare experts to discover that most patient safety errors are due to issues with systems rather than “bad” individuals, and that some systems are more prone to errors than others.

Common sense and practical experience dictate that organizations with effective reporting systems are able to learn from smaller mishaps and incidents so as to forestall serious workplace accidents (Reason, 1997; Connell, 1998; Johnson, 2001; 2001; Sullivan, 2001).

The 2007 medical staff standards of The Joint Commission change the peer review process by strengthening and extending it.

Imagine you’re a nurse on the Code Team, rushing to respond to a patient who has just gone into cardiac arrest.

One of the biggest challenges in improving patient safety is engaging staff members to learn and accept new behaviors.

Though studies continue to show that communication failure is a major cause of adverse medical events, we decided to test this relationship by reviewing the experience of the Veterans Health Administration, a large integrated health system.