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- Communication Improvement 4
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 8
- Human Factors Engineering 1
- Legal and Policy Approaches 4
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Medical Complications 3
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
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Search results for "Book/Report"
- Emergency Medicine
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.
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.
Learning organizations are capable of addressing problems through information sharing and learning from past experience to facilitate improvement and innovation. Large system failure occurs when such interventions are not disseminated and implemented. This report discusses the need to ensure that lessons learned in military trauma care are acted on and sustained and recommends that this information be translated for the civilian health system as a way to reduce preventable patient harm in trauma care.
Fingar KR, Barrett ML, Elixhauser A, Stocks C, Steiner CA. HCUP Statistical Brief #195. Rockville, MD: Agency for Healthcare Research and Quality; November 2015.
Defining preventability has become increasingly important due to its use as a measure for cost and reimbursement mechanisms. This report presents data on hospitalizations for conditions that might be averted through quality ambulatory care and reveals that preventable hospital stays decreased between 2005 and 2012.
Fisher JD, Freeman K, Clarke A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; May 2015.
The safety of emergency medical care delivered in conjunction with ambulance services has not been studied in the United Kingdom. Analyzing evidence associated with ambulance care, this scoping review found that inconsistent use of terminology was a problem and identified specific areas that require further research to develop safer models of prehospital care, including diagnosis and treatment, equipment use, and ambulance-to-hospital handover.
Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.
This report analyzes the literature discussing emergency department discharge processes and highlights elements of high-quality discharges and risk factors for suboptimal discharges. The in-depth review summarizes interventions currently implemented to augment discharge procedures, care coordination, and the identification of patients more susceptible to poor discharge.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
Ruoff G, ed. Cambridge, MA: CRICO Strategies; 2012.
This report analyzes malpractice claims from 90 hospitals across the United States to identify risks in emergency medicine.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
Retford, Notts, UK: NHS Alliance; 2011.
This publication discusses an initiative to monitor errors and near misses in after-hours care in the United Kingdom and reviews lessons learned during its first year of implementation.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3.
This report analyzes communication practices between emergency and primary care physicians and provides suggestions to improve and encourage meaningful communication.
Okemos, MI: Michigan Health & Hospital Association; October 2018.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This year's achievements include avoidance of 6392 instances of harm and safety-related savings in the state of nearly $81 million. Areas of focus for improvement work included high reliability, sepsis reduction, and opioid stewardship. The report also summarizes results of the 15-year experience of the collaborative.
Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.
This book presents tools, examples, strategies, and guidance to help health care leaders and front line personnel provide safe emergency care to pediatric patients.
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.
The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of Inspector General; January 2008. Report No. OEI-02-06-00310.
This report examines the operation and staffing of 109 physician-owned specialty hospitals and identifies shortcomings in the availability of emergency services.