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Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Study
Dowell D, Manwell LB, Maguire A, et al; MEMO Investigators. Healthc Q. 2005;8:suppl 2-8.
In this AHRQ-funded study, investigators conducted focus groups with patients to explore health care quality and safety issues. The authors conclude that patients can provide important insight for systems improvement and error reduction.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.
Journal Article > Study
Bagge M, Norris P, Heydon S, Tordoff J. Res Social Adm Pharm. 2014;10:791-800.
This qualitative study revealed that numerous changes were made to elderly patients' medications at hospital discharge, but many patients lacked understanding of the reasons for these changes and often reported that nobody had discussed the changes with them prior to discharge.
Journal Article > Review
A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms.
Reeve E, Moriarty F, Nahas R, Turner JP, Kouladjian O'Donnell L, Hilmer SN. Expert Opin Drug Saf. 2018;17:39-49.
Deprescribing has been recommended as a way to reduce polypharmacy. This review examines safety concerns associated with deprescribing among older patients and offers strategies to reduce risks. The authors suggest that further research is needed to understand potential harms of deprescribing and highlight the importance of shared decision-making to improve the safety of this process.