Narrow Results Clear All
- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches
Search results for ""
Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Solovy A. HHN Magazine (Hospitals & Health Networks). July 2005;79.
This article reports on the results of Hospitals & Health Networks' 2005 Most Wired Survey and Benchmarking Study. Results showed lower mortality rates among the 100 "Most Wired" hospitals, or those hospitals exhibiting successful information technology implementation.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
Journal Article > Study
Jha AK, Orav EJ, Ridgway AB, Zheng J, Epstein AM. Jt Comm J Qual Patient Saf. 2008;34:318-325.
The Leapfrog Group is a consortium of private and public employers who collectively purchase health care for more than 30 million Americans. Leapfrog recommends four evidence-based practices for implementation by hospitals: computerized provider order entry, intensivist coverage of critically ill patients, evidence-based hospital referral for high-risk patients, and adoption of the National Quality Forum's safe practices. This study found that hospitals that reported implementing at least one patient safety practice also provided slightly better care for myocardial infarction and congestive heart failure (as measured by publicly reported quality data), but not for pneumonia. The authors note that as the Leapfrog recommended practices are not directly tied to improving care quality for these specific conditions, implementation of Leapfrog patient safety practices likely indicates an overall commitment to providing higher-quality care.
Journal Article > Review
Wong ICK, Wong LYL, Cranswick NE. Arch Dis Child. 2009;94:161-164.
This review identifies factors that contribute to medication errors in pediatric care and describes risk reduction strategies.
Journal Article > Study
Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.
Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Am J Med Qual. 2009;24:278-286.
Computerized provider order entry (CPOE) continues to be hailed as a solution for medication-related errors and quality measures. However, concerns remain about the barriers to adoption and the unintended consequences that result after implementation. This study compared quality of care measures for hospitals with and without CPOE systems. The 264 hospitals with CPOE systems tended to be larger, not-for-profit, and teaching oriented. Investigators found that CPOE-driven hospitals performed better on 5 of 11 measures related to medication ordering and on 1 of 9 non–medication-related quality measures. The authors conclude that their findings build on past single-center CPOE implementation success stories and provide a more generalized link between CPOE and improved outcomes.