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- Culture of Safety
- Education and Training 1
- Error Reporting and Analysis 2
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 2
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Bethesda, MD: American Society of Health-System Pharmacists; 2006.
This report contains recommendations from a panel of experts convened to determine best practices for improving the safety of insulin use.
Journal Article > Study
Bates DW. Ann Intern Med. 2002;137:110-116.
This case study shares the experiences of a patient who suffered a medication error in receiving a dose of insulin inadvertently. The author reviews the epidemiology of medication errors and adverse drug events and shares a systems approach to medication errors, the role individuals and the system played in this particular case, and the potential prevention strategies to be considered. Finally, a comment about the institution's response to the event is presented to illustrate the importance of bridging what happens at the bedside with what needs to happen from the executive suite. This article is part of a collection entitled "Quality Grand Rounds," a series published in the Annals of Internal Medicine that explores quality issues and medical errors.
Journal Article > Study
Bosch M, Dijkstra R, Wensing M, van der Weijden T, Grol R. BMC Health Serv Res. 2008;8:180.
Improving teamwork among providers of different disciplines is a vitally important step in developing a culture of safety. Despite the development of measurement tools and intervention strategies for addressing inpatient teamwork, comparatively little research has addressed issues of team and organizational culture in the outpatient setting. This study sought to evaluate the relationship between teamwork (measured by the Team Climate Inventory) and organizational culture and chronic disease outcomes in ambulatory clinics. Neither teamwork nor organizational culture at the clinic level was significantly correlated with process or outcome measures, but the authors caution that current measurement methods are not optimal for assessing safety culture in small office practices. A prior trial of crew resource management in an outpatient clinic did result in improved diabetes care.
Cameron M. St. John's, NL: Government of Newfoundland and Labrador; 2009. ISBN: 978551463537.
This government report investigated certain laboratory tests conducted from 1997 to 2005 in Newfoundland and Labrador. The investigation revealed test result errors and failure to notify patients, as well as a lack of oversight. The report makes numerous recommendations with respect to ethics, standards of care, and disclosure of medical errors and adverse events. (Click on the volume titles on the cover page to view the full report.)
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.