Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-9.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.
Seminal studies in the United States have shown strong associations between nurses' working conditions and patient safety, with high patient-to-nurse ratios and greater patient turnover being linked to increased mortality. This multinational survey of nurses and patients found that improved nurse work environments and reduced patient-to-nurse ratios were linked to better perceptions of quality and patient satisfaction. Moderately strong correlations were found between patient satisfaction and nursing reports of care quality, although there were wide variations in both measures across different countries. This study lends additional support to the view that improving the work environment for nurses can strengthen patient safety.
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through his articles in The New Yorker on topics ranging from quality improvement to the costs of health care, and his books, Complications and Better. In his new book, The Checklist Manifesto: How to Get Things Right, Dr. Gawande elegantly describes the history of the checklist as a quality and safety tool, in fields ranging from flying airplanes to building skyscrapers. In health care, he focuses on the Michigan Keystone Project, in which the use of checklists led to a remarkable decrease in the rate of central line–associated bloodstream infections, and on his own work with the World Health Organization's Safe Surgery Saves Lives program, where checklist use was associated with a striking decrease in surgical complications. An AHRQ WebM&M interview with Dr. Gawande discusses professionalism, surgical errors, and patient safety. A Patient Safety Primer on checklists is also featured on AHRQ PSNet.
King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.
This memoir shares the story of Sorrel King's crusade to make medical care safer. Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation's foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.
This report summarizes results from a conference of consumers, health care professionals, and administrative leaders about improving the health care system and advancing patient-centered care. Key recommendations include involving patients and families in health care leadership, through measures such as patient advisory councils and partnering with community organizations. The report also emphasizes the role of health literacy in providing patient-centered care.
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose efforts to standardize safety practices led to remarkable reductions in ICU harm in Michigan hospitals. It goes on to a broader discussion of how checklists and decision support have reduced errors and transformed safety in critical care. Gawande also reflects on how implementation of standardized approaches often conflicts with the traditional physician culture, which prizes individual expertise over all else.
Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-3.
Disclosure of medical errors remains an important and challenging practice, with a past report providing thoughtful guidance on how to respond. This commentary addresses the humanistic aspect of what patients, families, and clinicians go through in trying to bring closure or forgiveness to the experience. Drawing from interviews highlighted in a documentary film, the authors share a number of specific themes not frequently addressed. These include feelings of concern by patients about the potential for further harm to occur, feelings of isolation by patients from their clinicians when they need them the most, and feelings of guilt by family members that often exceed those of providers. An AHRQ WebM&M commentary, perspective, and interview also discuss multiple facets of error disclosure.
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
In this book, the author presents several stories that illustrate the forces that shape physician decision-making and may lead to diagnostic mistakes. Borrowing from the field of cognitive psychology, a number of errors stemming from clinicians’ use of heuristics, or “rule of thumb” shortcuts, are highlighted. This book introduced these concepts on a popular level to many clinicians and the public. The book also discusses the role patients can play to minimize these mistakes. A prior AHRQ WebM&M perspective discussed diagnostic errors and provided advice for reducing cognitive slips.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Washington DC: National Academies Press; 2007. ISBN 0309101476.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
JCAHO; Joint Commission on Accreditation of Healthcare Organizations.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Bogner MSE, ed. Hillsdale, NJ: L. Erlbaum Associates; 1994. ISBN 9780805813852.
This book, published well in advance of the Institute of Medicine report To Err is Human, includes chapters by a number of leaders in their fields on a wide range of topics related to patient safety. Chapters include the Foreword by James Reason, Lucian Leape’s chapter on the preventability of medical injury, the chapter Operating at the Sharp End by Richard Cook and David Woods, the chapter on team performance in the operating room by Robert Helmreich and Hans-Gerhard Schaefer, the chapter on the handling of fatigue in various industries by Gerald Krueger, David Gaba’s chapter on human error in dynamic domains, and the Afterword by Jens Rasmussen.
Casey SM. Santa Barbara, CA: Aegean; 1998. ISBN 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 9780805063196.
In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.
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