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- Communication Improvement 2
- Culture of Safety 2
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- Error Reporting and Analysis
- Human Factors Engineering 1
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- Quality Improvement Strategies 3
- Teamwork 1
- Technologic Approaches 2
- Identification Errors 1
- Medical Complications
- Medication Safety 2
- Surgical Complications 3
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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Wisc Med J. 2006:105;1-86.
This special issue includes articles on programs and initiatives to improve the safety of health care. It also includes proceedings from a 2006 Wisconsin conference on patient safety.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Journal Article > Commentary
Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.
In October 2008, Medicare will put into effect a new policy that withholds payment for eight preventable complications of care, with plans already in place to expand this list in 2009. This initiative has prompted several discussions in the safety community, ranging from the business case for adopting such a policy to whether any of the targeted conditions can be accurately identified as present on admission. This commentary further explores the basis of Medicare's efforts and focuses on criteria that should be considered when withholding payment for complications of care. The authors provide a framework that requires each proposed complication to be important, measurable, and truly preventable to meet the burden of proof for inclusion. Only foreign objects retained after surgery and catheter-related blood stream infections serve as "wise and just" complications based on their assessment. While the authors acknowledge the opportunity for Medicare to align payment incentives and stimulate improvements in quality and reduce costs, they caution against rapid adoption and a failure to carefully evaluate the benefits and risks of the initiative.
Legislation/Regulation > Government Resource
Council recommendation on patient safety, including the prevention and control of healthcare associated infections.
Council of the European Union (2009).
This document provides a series of suggestions to improve patient safety in health care systems across the European Union.
Journal Article > Study
Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system.
Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173:2039-2046.
Health care–associated infections (HAIs) remain a major contributor to preventable morbidity and mortality in hospitalized patients, despite some progress in combating certain infections. This economic analysis combined a systematic review of estimates of costs attributable to HAIs with HAI incidence data to project hospitals' total financial burden caused by these infections in adult inpatients. The authors conclude that the 5 most common HAIs result in an annual cost to the health care system of nearly $10 billion. Since the majority of HAIs are considered preventable, this finding implies that considerable savings could be achieved through more rigorous HAI prevention efforts. Although the study is limited by the heterogeneous methods of determining costs used in the original studies, other studies have shown a relatively strong business case for hospitals to invest in efforts to prevent HAIs.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Journal Article > Study
Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.
Horn SR, Liu TC, Horowitz JA, et al. Spine (Phila Pa 1976). 2018;43:E1358-E1363.
This retrospective review of National Surgical Quality Improvement Program data on hospital-acquired conditions following elective spine surgery found that 3% of these cases had at least one hospital-acquired condition. The most common conditions were surgical site infection, followed by urinary tract infection and venous thromboembolism, all well-recognized conditions with known evidence-based prevention strategies.