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Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Washington, DC: National Quality Forum; 2005.
In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Journal Article > Study
Davis TC, Wolf MS, Bass PF III, et al. Ann Intern Med. 2006;145:887-94.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.
Journal Article > Study
Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand?
Engel KG, Heisler M, Smith DM, et al. Ann Emerg Med. 2009;53:454-7461.e15.
This study assessed emergency department (ED) patients' understanding of their diagnosis, treatment received, post-discharge care, and indications to return to the ED. Most patients had limited comprehension of at least one aspect of their care, most commonly pertaining to their post-discharge care. Although this study did not directly assess patients' health literacy, prior research has found correlations between limited health literacy and misunderstanding of instructions (such as those on prescription drug labels). The Joint Commission has published recommendations for improving patient-provider communication in order to address problems similar to those identified in this study.
Journal Article > Commentary
Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Jt Comm J Qual Patient Saf. 2009;35:377-383.
While the patient safety field originated in studies of error in hospitals, safety in ambulatory care remains relatively less studied. Even within ambulatory safety, few studies address safety issues in chronic disease management, despite the fact that most medical care is provided in this context. In this article, the authors use evidence and case vignettes to develop a conceptual model of ambulatory safety and discuss how this model differs from the classic Donabedian triad. The framework emphasizes the role of health systems (including care coordination and information technology) and patient factors (such as health literacy) as determinants of safety and health outcomes.
Journal Article > Study
Olson DP, Windish DM. Arch Intern Med. 2010;170:1302-1307.
Patients are increasingly being encouraged to take an active role in ensuring their own safety, but doing so will require close partnership between patients and their physicians. However, this survey of hospitalized patients and their physicians revealed fundamental gaps in patients' knowledge of their illness, with nearly 40% of patients being unaware of their diagnosis and 90% being unaware of potential medication side effects. Physicians tended to overestimate patients' understanding of their diagnosis and the plan of care. This study's findings are supported by prior research in the emergency department and outpatient setting. A case of suboptimal communication contributing to patient harm is discussed in this AHRQ WebM&M commentary.