The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
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.
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.
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.
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.
Paterson R. Auckland, NZ; Office of the Health and Disability Commissioner: April 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
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.
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