Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2020 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication efforts, and the convening of patient safety conferences for the state.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation.
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021; Epub Jan 6.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2020 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Atlanta, GA: Centers for Disease Control and Prevention; December 2, 2020.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2019 revealed reductions in central line–associated bloodstream infections and no substantive change in surgical site infections.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2019-June 2020, reported pressure ulcers increased while treatment delays and surgery-related events decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving team communication and use of hospital data to reduce delays.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33(1):mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.
Horsham, PA: Institute for Safe Medication Practices; 2020.
This updated report outlines 16 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2020 update includes new practices that are associated with opioids and automated dispensing cabinet overrides. ISMP is currently seeking insights as to the implementation of the current best practices. Survey responses are due by July 30, 2021.
Dinnen T, Williams H, Yardley S, et al. BMJ supportive & palliative care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. A PSNet Human Factors Primer on human factors expands on these concepts.
DiCuccio MH. Journal of patient safety. 2015;11:135-42.
This systematic review evaluated the evidence linking safety culture and patient outcomes, including satisfaction, falls, readmission rates, medication errors, and mortality. Due to its positive effect on outcomes, the authors call for more research to identify initiatives that can enhance safety culture.
Paciotti B, Roberts KE, Tibbetts KM, et al. Joint Commission journal on quality and patient safety. 2014;40:187-92.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
Block L, Jarlenski M, Wu AW, et al. Journal of Hospital Medicine. 2014;9.
Resident physician duty hour regulations have primarily been driven by an impetus to improve patient safety, but evidence supporting this effect is largely lacking. This observational study compared patient outcomes between a resident medicine service and hospitalist (nonresident) medicine service at a large academic medical center, before and after the 2011 ACGME work hour reforms. Overall there were no significant differences in length of stay, 30-day readmission, inpatient mortality, hospital-acquired conditions, or intensive care unit admissions. A New England Journal of Medicine roundtable discussion explored the past decade of duty hour reforms, and a recent commentary by Drs. Halpern and Detsky called for more research evaluating the intended and unintended effects of these mandates. An AHRQ WebM&M perspective reviewed evidence surrounding the impact of resident duty hour limits on safety in health care.
Nguyen H-T, Pham H-T, Vo D-K, et al. BMJ quality & safety. 2014;23:319-24.
An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
In the context of public reactions to the Francis report, this commentary discusses why the poor conditions were missed and how to prevent failures from recurring once they are identified. The authors advocate for a just culture that balances blame and accountability to address complexities in the health care setting.
Provost SM, Lanham HJ, Leykum LK, et al. Health care management review. 2015;40:2-12.
Based on principles from high reliability organizations, huddles are increasingly being used to improve safety in hospitals. This study outlines a theoretical framework for how huddles can promote high-reliability behaviors in health care settings, mainly by accommodating communication, fostering interdisciplinary relationships, and enhancing safety culture.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
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