Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Distractions and interruptions are prevalent in health care delivery. This conference report reviews types of distractions in anesthesiology, their likelihood to introduce significant risks into care processes, and strategies to help manage distractions.
Henriksen K; Dymek C; Harrison MI; Brady JP; Arnold SB.
Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.
This publication summarizes patient safety leaders' observations of changes made in the decade following To Err is Human. The discussion offers suggestions for further improvement of patient safety initiatives and research, including developing an educational campaign and creating clearer goals for patient safety activities.
This publication discusses the plenary session from the 2009 National Patient Safety Congress. A panel of distinguished patient safety leaders, including Drs. Donald Berwick, Carolyn Clancy, Lucian Leape, and Dennis O'Leary, reflected on the impact of To Err Is Human and shared insights on the past and future of safety work.
Wong DA, Lewis B, Herndon JH, et al. The Journal of Bone and Joint Surgery-American Volume. 2009;91.
This article highlights the discussion at a joint symposium between Canadian and American orthopedic associations. The authors discuss the state of patient safety, wrong-site surgery, and future areas for improvement initiatives.
Jha AK, DesRoches CM, Campbell EG, et al. N Engl J Med. 2009;360:1628-38.
Increasing the use of electronic health records (EHRs) is a major policy priority, as implementation has been slow both in the United States and in other countries. This survey of nearly 3000 US hospitals found that less than 2% had a fully functional EHR (defined as incorporating clinical documentation, laboratory and imaging results, computerized provider order entry, and clinician decision support). Survey respondents cited cost and maintenance considerations as major barriers to adopting EHRs, concerns that have been cited in prior research. Given that most outpatient practices also do not use electronic records, the authors recommend several policy initiatives to spur EHR implementation.
The authors summarize the plenary talks and panel discussions on topics such as leadership's role in leading change, the importance of disclosure and apology, and the role of nurses in achieving patient safety.
Denham CR, Bagian JP, Daley J, et al. J Patient Saf. 2005;1:154-169.
The authors discuss six barriers to implementing patient safety efforts in hospitals. The article is a companion piece to the plenary session from the 2005 National Patient Safety Foundation (NPSF) Congress.
This article summarizes programs presented at the 2004 American Society of Health-system Pharmacists (ASHP) Leadership Conference. Speakers covered topics such as value-based leadership, using information technology to improve medication safety, and strategies for meeting standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
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