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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Patient Safety.

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Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.

Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area

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June 12, 2020

Formerly known as the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the University of Arkansas for Medical Sciences (UAMS) High-Risk Pregnancy Program links clinicians and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy services, maternal-fetal medicine specialists, and prenatal genetic counselors are located.

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

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June 12, 2020

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.

Patient Safety.

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National Pharmacy Association; NPA.

This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

Patient Safety.

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GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.

Patient Safety.

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Minnesota Hospital Association; MHA.

This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.

Patient Safety Papers 5.

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Baker GR, ed. Healthc Q. 2010;13(Spec No):1-136.

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.

Treatment Challenges After Discharge

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November 1, 2010

A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.

Challenges faced in providing safe care in rural perinatal settings.

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Jukkala AM, Kirby RS. MCN Am J Matern Child Nurs. 2009;34:365-371.

This survey of rural hospitals in the southern United States found that hospitals with fewer than 125 deliveries per year were relatively less prepared to administer neonatal resuscitation. As well, one-third of hospitals did not have an established method for transferring patients to tertiary care hospitals.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

Patient Safety.

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Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.

This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

ISMP medication error report analysis.

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Cohen MC.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

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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.

ISMP medication error report analysis.

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Smetzer JL; Cohen MR.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

ISMP medication error report analysis.

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Smetzer JL; Cohen MR.

This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

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Hunt EA, Walker AR, Shaffner DH, et al. Pediatrics. 2008;121:e34-e43.

This study of hospital-based mock codes found significant delays and deviations in the care of pediatric patients requiring resuscitation. The authors advocate for use of simulation to help identify opportunities for educational intervention. A similar study in the adult population found delays in treatment of in-hospital cardiac arrests, with lower survival rates in patients with slower response rates. A past AHRQ perspective discusses the role of simulation and what it adds to traditional classroom-based teamwork training.

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