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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
The Healthcare Commission. London, UK: The Stationary Office; 2008.
This report shares findings from a 5-year analysis of the state of health care in the United Kingdom. It reveals that while awareness of patient safety has improved since the first report in the series, the UK health system needs to be more consistent in its application of patient-centeredness concepts to fully promote quality.