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Search results for ""
Hallmarks of quality and patient safety recommended baccalaureate competencies and curricular guidelines to ensure high-quality and safe patient care.
J Prof Nurs. 2006;22:329-330.
This consensus document represents the work of a task force convened to identify essential competencies that should be covered by undergraduate nursing programs to provide an effective foundation in quality and safety.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Shorr AS. Healthc Exec. March-April 2007;22:19, 21-22, 24, 26.
The author discusses executive accountability for patient safety and active involvement in creating a patient-centric culture.
Journal Article > Commentary
Denham CR. J Patient Saf. 2007;3:43-54.
The author interviews patient safety leaders on the role of the "patient safety officer" and suggests guidelines for developing this position.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. J Healthc Manag. 2007;52:188-204; discussion 204-205.
This study sought to identify organizational characteristics associated with greater implementation of patient safety systems and found that only Joint Commission accreditation predicted more comprehensive use of such measures.
Dworkin A. The Oregonian. June 20, 2007:A01.
This article reports on dispensing errors made by Oregon pharmacists and the fines imposed as penalty for those errors.
Wachter RM. Los Angeles Times. July 1, 2007:M1.
Recently, California health officials have argued to revoke the license of King-Harbor Hospital, owing to concerns about patient safety. In this op-ed piece, the author suggests that this urban hospital is unable to provide reliable and safe care to its patients despite repeated attempts to improve the organization.
Callender AN, Hastings DA, Hemsley MC, Morris L, Peregrine MW. Washington, DC: US Department of Health and Human Services Office of the Inspector General; June 29, 2007.
This report outlines the fiduciary and corporate responsibilities of board members to support quality and safety in hospitals and provides questions to help them examine the scope of these efforts in their organizations.
Levy S. Drug Topics. July 9, 2007.
This article reports on ways in which chain pharmacies are improving the reliability of medication dispensing, such as better training for pharmacy employees and use of technology.
Journal Article > Commentary
Sheridan SS, Hatlie MJ. Patient Saf Qual Healthc. July/August 2007;4:22-26.
This article discusses tort system reform and reproduces a statement given before the National Patient Safety Foundation Congress on how patients and families are affected by medical error and concomitant litigation.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Journal Article > Study
A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.
Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. 2007;82:1040-1048.
Efforts to address professionalism and individual accountability remain important in patient safety, even with the role systems play in poor patient outcomes. Past studies have tried to predict poor professional behavior based on medical school performance, and concerns have also been raised as a result of changes in residency training requirements. This article describes the efforts of one academic institution in teaching professionalism. The authors share their approach and model for addressing disruptive behavior, and their related interventions to prevent it. An AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
Oakbrook Terrace, IL: The Joint Commission; November 2007.
Building on its inaugural publication, this report summarizes the quality and safety of care delivered to hospitalized patients between 2002 and 2006. The report suggests that hospital performance consistently improved from year to year as measured by adherence to evidence-based treatments for heart attacks, heart failure, and pneumonia, as well as more recent measures of surgical care. While similar improvements were noted in compliance with National Patient Safety Goals, significant room for improvement remains on additional quality measures, and noted variability exists in performance by hospital and by state. The report emphasizes the Joint Commission's efforts to improve performance measurement and reporting requirements in future years to adequately reflect the organization's goal of improved health outcomes. A past AHRQ WebM&M commentary discussed the unintended consequences of the public reporting of hospital quality.