What happens when healthcare innovations collide?

Sachin R. Pendharkar; Jaana Woiceshyn; Giovani J C da Silveira; Diane Bischak; Ward Flemons; Finlay McAlister; William A. Ghali

Commentary

What happens when healthcare innovations collide?

January 6, 2016

Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. BMJ Qual Saf. 2016;25(1):9-13.

View more articles from the same authors.

Innovation within a health care system can be hindered when different interventions compete for time, attention, and funding. This commentary discusses insights from a health system that, due to restructuring, found various transition improvement initiatives at odds with one another. The authors review lessons learned that can be applied by organizations facing similar challenges with competing safety efforts.

PubMed citation

Available at

Related Resources From the Same Author(s)

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study).

November 6, 2013

A framework to assess patient-reported adverse outcomes arising during hospitalization.

August 24, 2016

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission.

December 6, 2017

Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data.

October 12, 2016

Advancing measurement of patient safety culture.

October 15, 2008

Determinants of adverse events in hospitals—the potential role of patient safety culture.

February 27, 2008

Does surgeon fatigue influence outcomes after anterior resection for rectal cancer?

June 18, 2008

Measuring safety of healthcare: an exercise in futility?

January 15, 2020

Breaking the silence of the switch—increasing transparency about trainee participation in surgery.

July 29, 2015

The efficacy of computer-enabled discharge communication interventions: a systematic review.

February 9, 2011

The costs of developing, implementing, and operating a safety learning system in community practice.

December 11, 2013

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates.

March 3, 2021

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers.

September 7, 2011

Cost-effectiveness of a quality improvement programme to reduce central line–associated bloodstream infections in intensive care units in the USA.

October 15, 2014

Adverse respiratory events in anesthesia: a closed claims analysis.

March 6, 2005

The alarming reality of medication error: a patient case and review of Pennsylvania and national data.

November 16, 2016

'August is always a nightmare': results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey.

September 14, 2011

The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram.

November 7, 2012

Predicting patient complaints in hospital settings.

October 22, 2008

Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.

November 8, 2006

Review of computerized physician handoff tools for improving the quality of patient care.

December 12, 2012

Opportunities and challenges for quality and safety applications in ICD-11: an international survey of users of coded health data.

February 17, 2016

Use of simulation-based education to reduce catheter-related bloodstream infections.

August 19, 2009

A novel approach to increase residents' involvement in reporting adverse events.

May 18, 2011

Drone delivery of medications: review of the landscape and legal considerations.

February 21, 2018

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.

March 26, 2008

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

January 31, 2007

Design for patient safety: a systems-based risk identification framework.

August 15, 2018

Identifying and reconciling patients' allergy information within the electronic health record.

July 6, 2022

Beyond FMEA: the structured what-if technique (SWIFT).

September 26, 2012

What is the value and impact of quality and safety teams? A scoping review.

November 16, 2011

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

From guideline to order set to patient harm.

April 4, 2018

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy.

September 11, 2019

Pediatric quality and safety: a nursing perspective.

May 11, 2016

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

August 22, 2012

Hospital discharge documentation and risk of rehospitalisation.

May 4, 2011

Standardizing hospital discharge planning at the Mayo Clinic.

January 12, 2011

Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.

March 27, 2013

An intervention to increase situational awareness and the Culture of Mutual Care (Foco) and its effects during COVID-19 pandemic: a randomized controlled trial and qualitative analysis.

January 20, 2021

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

March 6, 2005

The Safe Tables Collaborative: a statewide experience.

May 4, 2011

How useful are voluntary medication error reports? The case of warfarin-related medication errors.

January 9, 2008

Findings from the ISMP Medication Safety Self-Assessment for hospitals.

March 6, 2005

The association between night or weekend admission and hospitalization-relevant patient outcomes.

January 26, 2011

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

November 15, 2017

Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval.

April 9, 2014

Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study).

February 3, 2016

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

October 3, 2012

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.

February 25, 2009

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

January 29, 2014

Inadequate preoperative team briefings lead to more intraoperative adverse events.

May 27, 2015

Can patients report patient safety incidents in a hospital setting? A systematic review.

May 23, 2012

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

December 8, 2021

Surgical count process for prevention of retained surgical items: an integrative review.

May 11, 2016

Markers for enhancing team cognition in complex environments: the power of team performance diagnosis.

August 1, 2007

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study.

April 24, 2013

Teamwork behaviours and errors during neonatal resuscitation.

March 24, 2010

Quality and variability of patient directions in electronic prescriptions in the ambulatory care setting.

April 18, 2018

Determining medication errors in an adult intensive care unit.

October 18, 2023

An innovative approach to the surgical time out: a patient-focused model.

June 29, 2016

Medication errors in the care transition of trauma patients

December 18, 2019

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality.

August 3, 2022

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

April 28, 2010

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

November 25, 2015

Participation in EHR based simulation improves recognition of patient safety issues.

December 10, 2014

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

March 23, 2022

Application of patient safety indicators internationally: a pilot study among seven countries.

August 5, 2009

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

April 20, 2011

What is known about adverse events in older medical hospital inpatients? A systematic review of the literature.

September 4, 2013

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

February 2, 2022

Teaching nurses to make clinical judgments that ensure patient safety.

August 14, 2019

Safely practicing in a new environment: a qualitative study to inform physician onboarding practices.

May 13, 2020

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

Effective surgical safety checklist implementation.

January 30, 2005

Analysis of prescribers' notes in electronic prescriptions in ambulatory practice.

March 23, 2016

When doing wrong feels so right: normalization of deviance.

March 25, 2015

Improving patient safety in radiation oncology.

March 16, 2011

What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS.

June 5, 2019

Mitigating error vulnerability at the transition of care through the use of health IT applications.

February 20, 2013

A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.

October 17, 2012

Patient safety in palliative care at the end of life from the perspective of complex thinking.

August 16, 2023

Automated and electronically assisted hand hygiene monitoring systems: a systematic review.

June 18, 2014

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Adverse events in healthcare: learning from mistakes.

September 3, 2014

Reducing anticoagulant medication adverse events and avoidable patient harm.

April 9, 2008

Effect of critical access hospital conversion on patient safety.

November 28, 2007

Patient safety outcomes in small urban and small rural hospitals.

February 17, 2010

The girl who cried pain: a bias against women in the treatment of pain.

January 2, 2001

Prescription for error: process defects in a community retail pharmacy.

December 19, 2007

What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour.

September 21, 2022

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

A systems approach to identify factors influencing adverse drug events in nursing homes.

June 27, 2018

Beyond service quality: the mediating role of patient safety perceptions in the patient experience–satisfaction relationship.

October 12, 2011

A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients.

July 26, 2017

Intervention study for the reduction of medication errors in elderly trauma patients.

September 2, 2020

Quality and safety practices among academic obstetrics and gynecology departments.

August 30, 2023

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

June 20, 2007

Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.

April 15, 2015

Related Resources

Honest communication and social asymmetries inside a hospital: pitfalls for clinicians.

June 15, 2022

Research to improve diagnosis: time to study the real world.

January 26, 2022

An evidence-based tool (PE for PS) for healthcare managers to assess patient engagement for patient safety in healthcare organizations.

May 26, 2021

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home.

February 17, 2021

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training

January 13, 2021

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level.

August 26, 2020

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.

March 11, 2020

Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care

October 2, 2019

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Creating a just culture: the Ottawa Hospital's experience.

August 21, 2019

Evidence-based medicine: a cornerstone for clinical care but not for quality improvement.

May 15, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals.

March 13, 2019

Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety.

January 30, 2019

Measurement and Monitoring of Safety in Canada: CPSI Safety Improvement Project.

October 24, 2018

Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.

August 8, 2018

How to incorporate quality improvement and patient safety projects in your training.

May 23, 2018

Latent risk assessment tool for health care leaders.

April 25, 2018

Piloting a patient safety and quality improvement co-curriculum.

January 17, 2018

Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.

December 20, 2017

Organisational paradoxes in speaking up for safety: implications for the interprofessional field.

December 13, 2017

Framework for direct observation of performance and safety in healthcare.

November 29, 2017

The Case for Investing in Patient Safety in Canada.

October 25, 2017

Effectively leading for quality.

October 4, 2017

Understanding middle managers' influence in implementing patient safety culture.

September 13, 2017

Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives.

August 23, 2017

What we know about designing an effective improvement intervention (but too often fail to put into practice).

June 28, 2017

A quality improvement approach to standardization and sustainability of the hand-off process.

May 31, 2017

See More About The Topic

Hospitals

Health Care Executives and Administrators

Medicine

Epidemiology of Errors and Adverse Events

Quality Improvement Strategies

What happens when healthcare innovations collide?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

What happens when healthcare innovations collide?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site