Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Patient harm associated with advance directive interpretation errors is rare, but these mistakes can have negative psychological consequences for care teams, patients, and families. Discussing research exploring factors that contribute to these misunderstandings, this article recommends actions to help patients articulate end-of-life care preferences and ensure those instructions are accurately shared with their families and the clinical teams acting on their behalf.
Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis found that common problems included drug incompatibility and drug–drug interaction. The article cautions against relying on drug ordering alerts as the sole strategy for preventing potentially harmful prescribing.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, this article recommends strategies to reduce risks associated with prescribing, including use of computerized provider order entry systems and standard order sets.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Determining the preventability of an adverse event remains a challenge. Summarizing the evidence around identifying whether a hospital readmission was avoidable and if preventable readmission rates are a reasonable measure of quality and safety, this article proposes that research focus on developing quality indicators that are more relevant to patients.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
Recently, diagnostic error has garnered much discussion and examination, but further research is needed to understand and track such errors. This article reviews evidence on the topic to illustrate measurement challenges and includes a sociotechnical model to identify, assess, and address diagnostic errors.
Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70.
This article analyzed data on dietary errors submitted to a state reporting program and found that more than 60% of patients received trays containing food items to which they were allergic. Recommendations to prevent such errors include standardizing practices and using whiteboards as communication tools.
Full disclosure programs have shown to be effective mechanisms for early resolution of adverse events. This article reveals one early adopter's experience with full disclosure and provides insights from the architects of the program to guide others in implementing similar strategies and spread success associated with the approach.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
Effective monitoring can enable early detection of deteriorating patients while reducing nuisance alarms. Relating how one hospital implemented round-the-clock monitoring and adjusted alarm thresholds, this article reports results of the program such as fewer patient transfers to the intensive care unit and no subsequent adverse events.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
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.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
This analysis of reports submitted to the Pennsylvania Patient Safety Authority discusses why wrong-patient medication errors occur and reveals strategies to prevent mistakes during transcription and administration.
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