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Search results for "Book/Report"
- Education and Training
Omaha, NE: Nebraska Coalition for Patient Safety; 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected between 2008 and 2018, offers insights drawn from an analysis of nearly 1000 incident reports, and reviews root causes analyses on incidents such as patient suicide.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Burnout can diminish the safety of clinicians, students, health care workers, and patients. This report suggests institutions apply design thinking and systems thinking methods to develop interventions to reduce burnout and stress. A past Annual Perspective covered the impact of burnout on patient safety.
Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
The role of hospital boards in influencing and financing efforts to improve safety is of recognized importance. However, leaders must have the skills and mindset needed to understand and perform quality governance responsibilities. This report provides a framework drawn from the Institute of Medicine six elements of quality to clarify responsibilities of trustees and health system leaders with regard to quality oversight.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
The third edition of this widely read textbook, written by national leaders in patient safety, provides an in-depth introduction to the field. The new edition uses case studies to discuss the history of the patient safety movement, the epidemiology of safety hazards, specific error types, and strategies to improve safety in clinical microenvironments and at the organizational level. Substantial new content has been added to highlight emerging areas of the field, such as safety culture, policy and regulatory initiatives to improve safety, and diagnostic errors.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Chicago, IL: American Hospital Association; 2017.
The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help health care systems target eight areas of focus that have potential to reduce the impact of opioid misuse, including improving prescribing practices, collaborating with communities, and educating patients.
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
Incorporating patient safety in education and learning environments can augment physician engagement in quality and safety work. This publication outlines how organizations can enable new clinicians to develop a long-term patient safety focus through leadership involvement in safety culture and an infrastructure that supports reporting, transparency, and measuring improvements.
Schnell M, Currie J. Cambridge, MA: National Bureau of Economic Research; August 2017. Working Paper No. 23645.
Overprescribing is seen as a contributor to the current opioid epidemic. This working paper explores the potential role that physician education and medical school quality have on prescribing behaviors. Analyzing data from 2006–2014, the authors found that lower ranked institutions wrote more opioid prescriptions and conclude that physician education may be a logical focus of improvement efforts. A recent PSNet perspective explored opioid overdose as a patient safety problem.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Leadership has a responsibility to establish a culture that fosters staff and clinician well-being as a key component of patient safety. This white paper highlights the importance of enabling joy at work, reviews examples of organizations that have tested strategies to improve joy in work, and provides measurement tools to monitor the effect of initiatives over time. A past PSNet interview discussed joy in practice and physician professional satisfaction.
Croskerry P, Cosby K, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
Efforts to enhance the reliability of the diagnostic process must take various elements into consideration. This publication discusses diagnosis, the role of reasoning in the process, challenges to diagnostic effectiveness, and strategies to make diagnosis more reliable such as patient engagement and using information technology.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2017.
Medication safety is a global health care concern. This workshop proceedings report highlights expert opinion on how to improve the clarity of medication information and the way it is communicated to patients. Panelists focused on elements of the process such as the patient experience, health literacy, medication instructions, and design of medication packaging.
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance—A Handbook for Acute Care Health Professionals.
Brindley P, Cardinal P, eds. Ottawa, ON, Canada: Royal College of Physicians and Surgeons of Canada; 2017. ISBN: 9781926588414.
Nontechnical skill development has gained attention as a way to enhance patient safety. This publication highlights how crisis resource management can help develop nontechnical expertise to enhance team performance. Strategies covered in the text include situational awareness, team communication, decision making, and leadership in the acute care environment.
Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678.
The Crossing the Quality Chasm report provided a framework to improve quality and safety in health care. This publication draws on the six aims for quality outlined in the report to review core competencies, knowledge, and attitudes for safe nursing care. Topics covered include nurses as leaders, teamwork, and patient-centered care.