American Board of Quality Assurance and Utilization
Event Description: This two-day in person conference will focus on "Transformational Leaders: Redesigning Population Health Through Technology, AI, and Resilience." Attendees will identify how quality, financial, and clinical outcomes have improved by leveraging technology to maintain a sustainable path to quality health care, while uncovering where we are still vulnerable.
Institute for Healthcare Improvement. Boston, MA and online. August 31-October 14, 2022.
Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Armstrong Institute for Patient Safety and Quality. June 14 and 16, 2022
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Liu L, Chien AT, Singer SJ. Health Care Manage Rev. 2022;Epub Apr 30.
Work conditions can impact clinician satisfaction and the quality and safety of the care they provide. This study sought to identify the combination of systems features (team dynamics, provider-perceived safety culture, patient care coordination) that positively impact work satisfaction in primary care practices. Results showed a strong culture of safety combined with more effective team dynamics were sufficient to lead to improved work satisfaction.
Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;Epub May 2.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.
Halverson CC, Scott Tilley D. Nurs Forum. 2022;57:454-460.
Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.
Hansen M, Harrod T, Bahr N, et al. Acad Med. 2022;97:696-703.
Strong physician leadership during clinical crisis can help improve patient outcomes. In this randomized controlled trial, obstetrics-gynecology and emergency medicine residents participated in one of three study arms using high-fidelity mannequins. One study arm received a bespoke leadership curriculum, one received a modified version TeamSTEPPS curriculum, and the third received no leadership training. Participants in both curriculum arms improved leadership scores from “average” before the training to “good” following the training and continuing to six months. The control arm remained unchanged at “average” before and after.
Health profession schools are increasingly using interprofessional simulation-based education (IP-SBE) for learners to understand each other’s roles in team-based care. Learners’ ability to feel psychologically safe during IP-SBE is necessary for full learner participation. This scoping review analyzed 27 studies of psychological safety within IP-SBE. Learners were more likely to feel safe in well-designed simulations with facilitators who are experienced in pre- and de-briefing. Barriers to psychological safety included hierarchy, being observed, uncertainty, and poorly designed and delivered simulations.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Violence towards healthcare workers can result in harm for staff and patients. This article describes data collected during the first three years of a new statewide incident reporting system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals. Over the three-year period, hospitals reported between 0 and 6 incidents per staffed bed but qualitative analyses revealed variable reporting procedures among hospitals.
Savva G, Papastavrou E, Charalambous A, et al. Sr Care Pharm. 2022;37:200-209.
Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.
Sittig DF, Lakhani P, Singh H. J Am Med Inform Assoc. 2022;29:1014-1018.
Transitions from one electronic health record (EHR) system to another can increase the risk of patient safety events. Using the principles of requisite imagination, this article outlines six recommendations for safe EHR transitions through proactive approaches, process improvement and support for healthcare workers.
Strube‐Lahmann S, Müller‐Werdan U, Klingelhöfer‐Noe J, et al. Pharmacol Res Perspect. 2022;10:e00953.
Patients receiving home care services are vulnerable to medication errors. Based on survey feedback from 485 home care nurses in Germany, this study found that regular medication training and use of quality assurance principles (i.e., double checking) can decrease the incidence of medication errors in home care settings.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
Trbovich PL, Tomasi JN, Kolodzey L, et al. Pediatr Crit Care Med. 2022;23:151-159.
Intensive care units (ICU) are high-risk environments. Based on direct observations, these researchers identified 226 latent safety threats affecting routine care activities in pediatric ICUs. Findings indicate that threats persist regardless of whether individuals comply with or deviate from policies and protocols, suggesting the need for targeted interventions beyond reinforcing compliance.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:B2-B9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
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