This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Roter DL, Wolff J, Wu A, et al. BMJ Qual Saf. 2017;26:508-512.
Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Tothy AS, Limper HM, Driscoll J, et al. Jt Comm J Qual Patient Saf. 2016;42:281-5.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-7.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.
Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.
This online resource provides instructions and templates for implementing team-based, collaborative care. This group's collaborative care model has received a John M. Eisenberg Award for contributions to patient safety.
Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.
Litchfield IJ, Bentham LM, Lilford RJ, et al. Br J Med Pract. 2015;65:e133-e140.
This interview study revealed shortcomings in the process for notifying patients of test results, mirroring findings from prior studies. Patients expressed a desire for consistent and timely test result notification and noted deficiencies in current processes.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Turner K, Frush K, Hueckel R, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
Rifkin D. New York Times. November 16, 2009;Science Desk:5.
Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality improvement procedures might lead providers to ignore important contextual information—from patients—that also contributes to safe care.
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