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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Clinical Information Systems 2
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications
- Medication Safety 3
- Surgical Complications 1
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Special or Theme Issue
Health Aff (Millwood). 2018;37:1723-1908.
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Journal Article > Review
Callen J, Georgiou A, Li J, Westbrook JI. BMJ Qual Saf 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.
Journal Article > Study
Parente ST, McCullough JS. Health Aff (Millwood). 2009;28:357-360.
Despite widespread interest in the implementation of health information technology (HIT) and a systematic review demonstrating its positive effects on clinical outcomes, use of HIT remains limited. This AHRQ-funded study focused on the relationship between information technology implementation and patient safety by examining the incidence of selected patient safety indicators (PSIs) after implementation of HIT. Modest but significant improvements in some PSIs, including health care–associated infections, were associated with HIT implementation, corroborating the results of a prior study. The study did not assess whether specific elements of HIT, such as computerized provider order entry, were more effective at preventing errors.
Wanless S, McManaway J. Business Intelligence Network. August 30, 2005.
This article illustrates how hospitals can use their own administrative and patient data to reduce hospital-acquired infections.