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1 - 20 of 81

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.

Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.

Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present in health care. This publication shares four steps for organizational assessment algorithms to reduce their potential for negatively influencing clinical and administrative decision making.  

Gangopadhyaya A. Washington DC: Urban Institute; March 29, 2021.

Racial inequities affect the safety of medical care. This report analyzed 2017 discharge records using patient safety measures from 26 states to identify differences in adverse events and hospital-acquired conditions in Black and White patients. The results suggest that hospital availability for admission may be a driver to safety for both Black and White patient populations and point toward policy solutions for disparity reduction.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Alert fatigue is a recognized contributor to task burden and medical error. This report distilled monitoring, analysis, and optimization experiences to recommend strategies for improving the effectiveness of clinical audible alerts which includes the development of an overarching clinical decision support governance plan.

Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.

The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.  

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.
Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.
Root cause analysis has been widely adopted as a strategy to investigate events, despite questions regarding its effectiveness in health care. This revised pubication provides information about updated approaches to root cause analysis with an emphasis on idenitification of causal and contributing factors. It highlights the use of failure mode and effects analays as a complementary sentinel event examination strategy that enables design of proactive and reactive improvements.

Cumberlege J. London, England, Crown Copyright. July 8, 2020.

Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.

Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020.

Polypharmacy and medication overuse are known contributors to patient harm. This report outlines recommendations for combating medication overload. The recommendations include prescription review, issue awareness, point-of-care information access, training and industry influence reduction as tactics for improvement.

James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.

Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.
Farnborough, UK: Healthcare Safety Investigation Branch; 2019.
Design flaws and improper use of technologies that transfer medication and prescription information between provider environments is a known threat to patient safety. This report analyzes an anticoagulant overdose incident and found that information technology missteps contributed to the error.
Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-650.
One strategy to reduce the potential of opioid misuse is to limit access to unused medications in the home. Examining programs to safely collect unused prescription opioids for disposal and patient awareness and use of such programs, this report found that many adults are unaware these programs exist or choose to retain or sell unused prescription opioids rather than utilize safe disposal services.
Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501.
Human-centered processes, technology, and equipment design affect the safety of care. This book provides conference proceedings that explore the application of human factors and ergonomics expertise in six areas of health care (patient safety, health information systems, worker safety, clinician decision support, medical device development, and care of older patients) to improve safety.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Zheng K; Westbrook J; Kannampallil TG; Patel VL.
Challenges associated with electronic health record design and implementation contribute to interruptions, workarounds, and information overload. This book explores topics relevant to workflow disruptions that can degrade safe practice. The chapters review strategies such as data analysis techniques and human factors engineering to generate improvements.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
Inconsistent checking for and consideration of drug allergy alerts can diminish the safety of prescribing. This report from a multistakeholder work group provides evidence-based safe practices and recommendations for improvement, including standardizing documentation practices, actionable decision support, monitoring of alert effectiveness, and patient engagement.