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.
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.
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.
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.
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