The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Kwok Y-ting, Lam M-sang. BMJ Open Qual. 2022;11:e001696.
Changes in healthcare delivery and care processes as a result of the COVID-19 pandemic have increased the risk for falls. This study explored the impact of the COVID-19 pandemic and the implementation of a fall prevention program (focused on human factors and ergonomics principles) on inpatient fall rates at one hospital in Hong Kong. Findings indicate that fall rates significantly increased from pre-COVID to during the first wave of the pandemic (July-June 2020). The fall prevention program – implemented in July 2020 – led to a reduction of fall rates, but not to pre-pandemic levels.
Aviation safety relies on systems improvement rather than individual blame to understand and mitigate failure. This commentary applies principles key to that philosophy from commercial aviation to medicine. The authors highlight vigilance, team performance, and nontechnical skill development as strategies to improve reliability in critical care and surgery.
van de Plas A, Slikkerveer M, Hoen S, et al. BMJ Qual Improv Rep. 2017;6.
This commentary describes the results of a Six Sigma improvement project to reduce risks of parenteral medication administration errors that cause harm. Strategies tested included education, drug delivery modifications, and ensuring administration instructions were available.
Handoffs are comprised of a multitude of steps that are prone to communication error. This commentary describes how a hospital drew from Lean Six Sigma concepts to develop and implement a standardized handoff process. The effort achieved improvements and established a concrete method for nurses to apply safe communication and data sharing principles in the perioperative environment.
Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.
Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.
Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.
Ching JM, Williams BL, Idemoto LM, et al. Jt Comm J Qual Patient Saf. 2014;40:341-350.
This study highlights the use of Lean methodologies to facilitate implementation of barcode medication administration (BCMA) for hospitalized patients at Virginia Mason Medical Center. The introduction of BCMA led to significantly fewer medication errors. The concepts presented may be helpful for organizations employing new health technologies.
Ching JM, Long C, Williams BL, et al. Jt Comm J Qual Patient Saf. 2013;39:195-204.
Errors during administration are one of the most common types of medication errors, with one study showing that they occur in nearly 25% of doses in hospitalized patients. Lean methodology, derived from the Toyota Production System, is increasingly being used in health care as a way to design safer and more efficient systems of care. This study reports on the application of Lean approaches to improving medication administration safety. A redesigned medication administration system that incorporated human factors engineering techniques to minimize interruptions, implement barcode medication administration, and standardize nursing workflows resulted in a significant reduction in administration error rates. The study provides a useful example of how quality improvement techniques originally developed in other industries can be successfully applied in health care.
Blackmore C, Bishop R, Luker S, et al. Jt Comm J Qual Patient Saf. 2013;39:99-105.
Use of Lean methodology helped restructure the surgical instrument sterilization and preparation process according to human factors engineering principles, resulting in a sustained decrease in the instrument processing error rate.
Yamamoto J, Abraham D, Malatestinic B. Hosp Pharm. 2010;45.
In this collaboration between a pharmaceutical company and a hospital, Six Sigma methodology was used to standardize and improve the efficiency of insulin dispensing and administration. The intervention resulted in cost savings and a reduction in clinical adverse events.
Grout JR, Toussaint JS. Bus Horiz. 2009;53:149-156.
This commentary describes two concepts grounded in lean manufacturing and human factors science—stopping the line and the forcing function. The authors present methods to implement these strategies to drive improvement and reduce error in health care.
Zarbo RJ, Tuthill M, D'Angelo R, et al. Am J Clin Pathol. 2009;131:468-477.
Lean thinking strategies were applied to improve workflow and reduce misidentification errors in a surgical pathology laboratory. Following redesign of workflows, the overall misidentification rate reduced by 62% and a 95% reduction in slide misidentification defects.
Herzer KR, Mark LJ, Michelson JD, et al. J Patient Saf. 2008;4.
This study describes a comprehensive model that combined incident reporting systems, a multidisciplinary team approach, and Lean Six Sigma methodologies to successfully identify captured defects, and then implement more than 90 quality improvement projects.
Christianson JB, Warrick LH, Howard R, et al. Jt Comm J Qual Patient Saf. 2005;31:603-13.
The authors present the results of using Six Sigma methodology in four performance improvement projects at a large integrated health care system. They report on the lessons learned 3 years after implementation of the methodology.
Johnson T, Currie G, Keill P, et al. Jt Comm J Qual Patient Saf. 2005;31:554-60.
This 2005 American Hospital Association McKesson Quest for Quality Prize finalist reports on how using Six Sigma techniques, along with clinical information and business intelligence systems, facilitates strategic quality and safety alignment at their hospital.
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