Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Additional Filters
1 - 20 of 118
Joint Commission, National Quality Forum.
The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application procedure. The deadline for submitting an application for the 2021 award is September 30.

Jt Comm J Qual Patient Saf. 2021;47(8):463-488. 

The Eisenberg Award honors individuals and organizations who have made significant advancements in the pursuit of safe, high-quality health care. The 2020 honorees are Dr. David Gaba; Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL.

Oakbrook Terrace, IL: Joint Commission: June 8, 2021.

The Eisenberg Award honors individuals and organizations who have made critical achievements toward patient safety and quality improvement. The 2020 honorees are Dr. David Gaba, Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL. The awards will be presented virtually during the National Quality Forum's annual meeting in July.
Society to Improve Diagnosis in Medicine.
Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline for submitting a nomination for the 2021 award is September 6, 2021.
Furrow BR. Am J Law Med. 2020;46(2-3):219-235.
Efforts to track hospital quality and safety result in data and incentive complexities that detract from effective leadership decision making to improve safety. This article examines the juxtaposition of three emerging technologies to capture safety metrics and the pressures they bring to bear on effective management of adverse events and patient compensation schemes. The author suggests roles for leadership and Medicare to drive improvements.   

Jt Comm J Qual Saf. 2020;46(7):PI-II:2020;371-399.

The Eisenberg Awards honor individuals and organizations who have had noteworthy impacts on patient safety and quality improvement. This article collection highlights the work of the 2019 honorees: Gordon D. Schiff, MD; WellSpan Health, York, Pennsylvania; and HCA Healthcare, Nashville, Tennessee.
Classen DC, Holmgren AJ, Co Z, et al. JAMA Network Open. 2020;3.
Researchers measured the safety performance of electronic health record (EHR) systems using simulated medication orders that can lead to adverse events or death in order to evaluate how well the systems identified these errors, and the mitigating effect of computerized physician order entry and clinical decision support (CDS) tools. Safety performance increased moderately over the 10-year study period but there was considerable variation in performance based on the level of decision support (basic or more complex) and EHR vendor; safety risks persist despite EHR implementation.
Tedesco D, Moghavem N, Weng Y, et al. J Patient Saf. 2021;17(4):e327-e334.
Using nationally representative, all-payer discharge data, these authors examined temporal changes in AHRQ’s patient safety indicators (PSIs) and their association with national pay-for-performance reforms. From 2000 – 2013, the researchers found decreased rates for ten of thirteen PSIs and an increase in the rate of three PSIs (iatrogenic pneumothorax, postoperative sepsis, and postoperative physiologic or metabolic derangement). The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates.

2019 John M. Eisenberg Patient Safety and Quality Award Recipients. Oakbrook Terrace, IL; Joint Commission: May 13 2020.

The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2019 honorees are Gordon D. Schiff, MD; WellSpan Health, York, Pennsylvania; and HCA Healthcare, Nashville, Tennessee.
Hamadi H, Borkar SR, DHA LRM, et al. J Patient Saf. 2020.
Using data from the American Nursing Credentialing Center Magnet Recognition Program, the CMS Hospital-Acquired Conditions Reduction Program (HACRP), and survey data from the American Hospital Association, this study analyzed the association between hospitals’ nursing excellence accreditation and patient safety. The authors found that Magnet hospitals are more likely to have lower patient safety indicator (PSI) 90 scores but higher catheter-associated urinary tract infection and surgical site infection scores. The authors conclude that while the processes, procedures and educational aspects associated with Magnet recognition seem to improve nursing-sensitive patient safety outcomes, there are still opportunities for improvement.
Kravet S, Bhatnagar M, Dwyer M, Kjaer K, Evanko J, Singh H. Prioritizing Patient Safety Efforts in Office Practice Settings. Journal of patient safety. 2019;15(4):e98-e101.
Few models for systematically targeting patient safety risks in large health systems exist. For this quality improvement study encompassing five large health care delivery systems, key informants were interviewed at seven affiliated outpatient sites in an effort to understand why ambulatory care accounted for 30-35% of annual medical malpractice costs and missed or delayed diagnoses comprised about 50% of liability risk associated with office practices. Analysis revealed eight common patient safety risk domains; the single most important was communication and follow-up of diagnostic test results. The authors recommend employing their targeted approach to safety improvements in other large health systems.   
Novak A. Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management. 2019;39:19-27.
Robust safety culture improves many health outcomes but is difficult to achieve. In the Michigan Health and Hospital Association, an award for identifying safety hazards led to enhanced safety culture and reduced costs of care. A past PSNet perspective examined how leaders can foster safety culture improvements.
Smith PK, Amster A. Joint Commission journal on quality and patient safety. 2019;45:304-314.
This commentary describes how one health system developed and utilized an inpatient safety composite measure to track hospital-level performance on a select set of adverse events. The authors found that the tool successfully quantified improvement over time and suggest it can be used by other hospitals and health systems.
Fonarow GC. JAMA. 2018;320:2539-2541.
Using financial incentives to motivate health care improvement can have unintended consequences. This commentary examines how the Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program may have unintended consequences for postdischarge heart failure patients. The authors advocate for development of more effective policies and measures to reduce the potential for patient harm resulting from well-intentioned improvement efforts.
Shields MC, Stewart MT, Delaney KR. Health affairs (Project Hope). 2018;37:1853-1861.
Despite concerns regarding the safety and quality of care for hospitalized psychiatric patients, research exploring this area of patient safety is lacking. This commentary suggests several policy-focused strategies to improve the safety and patient-centeredness of inpatient psychiatric care, including payment reforms, incentive alignment, and increased funding for research.
Mohajer MA, Joiner KA, Nix DE. Academic medicine : journal of the Association of American Medical Colleges. 2018;93:1827-1832.
The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Centers for Medicare and Medicaid Services (CMS) and withholds payment to hospitals for several hospital-acquired conditions deemed to be preventable sources of patient harm. Prior research has shown that teaching hospitals, hospitals caring for more complicated and high-risk patients, and safety-net hospitals may be more likely to experience financial penalties under HACRP compared to nonteaching hospitals caring for less sick patients. These findings raised concerns regarding the possible unintended consequences related to pay-for-performance. Researchers sought to identify factors associated with HACRP performance and penalties. They found that teaching institutions and hospitals with higher case-mix index, length of stay, and those located in the Northeast or Western United States were more likely to receive penalties under the CMS program. A previous WebM&M commentary discussed the unintended consequences associated with publicly reported health care quality measures.
Frush K, Chamness C, Olson B, et al. Joint Commission journal on quality and patient safety. 2018;44:389-400.
The Eisenberg Award honors individuals and organizations who have made unique and sustained contributions to patient safety and quality improvement. This special collection of articles provides insights on the work of the 2017 honorees: Dr. Thomas Gallagher; Children's Hospitals' Solutions for Patient Safety; and LifePoint Health's National Quality Program.
Carroll AE. JAMA. 2017;318(18):1748-1749.
The provision of unneeded care can result in physical, financial, and psychological harm to patients. This commentary explores factors in health care that contribute to overtreatment and recommends reducing financial incentives for providing low-value care by increasing transparency regarding clinician conflict of interest and engaging insurers in changing clinician behaviors.