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- Communication Improvement 6
- Culture of Safety 4
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- Error Reporting and Analysis
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 1
- Medical Complications 3
- Medication Safety
- Overtreatment 1
- Surgical Complications 2
- Health Care Executives and Administrators 22
Health Care Providers
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- Non-Health Care Professionals 11
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Search results for "Book/Report"
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
Medication errors represent a significant source of preventable patient harm. Prior research has shown that medication errors occur frequently and are associated with a longer hospital stay and increased costs. This report from the Policy Research Unit in Economic Evaluation of Health and Care Interventions synthesizes the evidence regarding the burden of medication errors in the England. The authors estimate that 237 million medication errors occur annually and that 66 million of these errors may be clinically significant. The majority of potentially harmful errors likely occur in the outpatient setting where most medications in the National Health Service are prescribed. Costs associated with errors seem to vary widely. A prior WebM&M commentary described a case in which a medication error led to serious patient harm.
Disability Law Center. Boston, MA: February 2018.
Patients with mental health concerns are vulnerable to harm from medication errors. This investigation report describes factors that contributed to the deaths of two psychiatric inpatients and identifies weaknesses in monitoring, polypharmacy review, and off-label medication use as primary concerns.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Bonnie RJ, Ford MA, Pillips JK, eds. Washington, DC: National Academies Press; 2017.
Addressing the opioid epidemic will require a complex set of approaches to balance managing the potential for harms associated with opioid prescribing with ensuring effective pain management. This report from a consensus project explores the overarching issues associated with the opioid epidemic and outlines recommendations to improve opioid safety, including a heightened focus on public health solutions and enhanced patient management. A recent PSNet perspective discussed opioid overdose as a patient safety problem.
Boston, MA: CRICO Strategies; 2017.
Medication errors are a persistent challenge in health care that can occur at home or in the hospital. This analysis of more than 3000 medication-related malpractice claims found that 1 in 9 malpractice cases were associated with medication problems. The majority of medication safety incidents involved primary care providers or hospital-based nurses, and drugs commonly involved included analgesics, anticoagulants, and antibiotics.
Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.
Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.
Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13-26.
This government report reveals the need for a policy to ensure that veterans' medication needs are safely managed during transitions between health care providers.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
The Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2006. ISBN: 1845621182.
This report shares findings from an analysis of the state of health care in the United Kingdom. It reveals that one in five complaints received by the Healthcare Commission was safety related and that the UK health system needs to be more consistent in its application of tools and standards to fully promote safety and quality.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.