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.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.
Busch IM, Saxena A, Wu AW. J Patient Saf. 2021;17:358-362.
In this literature review, the authors identified patient-, clinician-, and institutional-level barriers to patient involvement in patient safety investigations. Potential strategies for overcoming barriers are also discussed, such as adopting a blame-free climate and enhancing clinician training in error disclosure and communication.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Hospitalized patients are at risk for medication errors. This set of tips seeks to help hospitalized patients contribute to the safe use of medications in their care. Recommendations include that patients know the reason they are taking each medication, speak up if any medications look different than previously, and talk with pharmacists when picking up discharge medications.
Patient safety is a global concern across the economic spectrum. This commentary summarizes activities associated with the first World Patient Safety Day and emphasizes how patient engagement is key to generating lasting improvements around the world to enhance patient safety.
Efforts to reduce misuse of prescription opioids must draw from public health and behavioral strategies to be successful. This news article reports on an analysis of surgical pain management practice changes used in 43 hospitals in response to prescription guidelines.
This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.
Solutions to address the opioid epidemic should focus on both public health and individual behaviors. This news article reports on an analysis of 5 years of Medicare data that revealed particular physician prescribing behaviors that exceed current guidelines and contribute to opioid misuse.
DesRoches CM, Bell SK, Dong Z, et al. Ann Intern Med. 2019;171:69-71.
OpenNotes provides patients with access to their health care provider’s documentation. This study found that patient access to such documentation may have the potential to improve medication adherence. A past PSNet interview discussed the OpenNotes project.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
The National Health Service (NHS) is a global leader in patient safety improvement. This website coalesces information and activities generated by three NHS improvement efforts: patient compensation, performance assessment, and fair resolution of appeals between the NHS and primary care contractors.
This video series illustrates techniques for patients to actively participate in their care. Episodes are available in both English and Spanish and are accompanied by transcripts. The Speak Up program was refreshed and relaunched in 2018 with new videos and topics.
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017.
Advocates for improving diagnosis emphasize the role of the patient as key to success. This report examines factors to consider when designing interventions to strengthen patient participation in the diagnostic process. Recommendations to enhance relationships with patients to reduce diagnostic error focus on managing misperceptions that can affect decision-making and communication.
Overdiagnosis and overtreatment present a challenge to patient safety. This news article reports on the prevalence of overtreatment among patients with cancer, how it can result in patient harm, and patient stories that illustrate the impact of overtreatment. A past PSNet interview discussed the patient safety implications of diagnostic radiology overuse.
Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.
The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.
Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.
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