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- Communication Improvement 10
- Culture of Safety 4
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 13
- Human Factors Engineering 3
- Legal and Policy Approaches 5
- Policies and Operations 2
- Quality Improvement Strategies 4
- Research Directions 1
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 2
- Medication Safety 3
- Psychological and Social Complications
- Surgical Complications 3
- Family Members and Caregivers 2
- Health Care Executives and Administrators 30
- Health Care Providers 25
- Non-Health Care Professionals 22
- Patients 9
Search results for "Book/Report"
- Psychological and Social Complications
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
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.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019.
Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers.
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.
Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Clinician burnout is a persistent threat to patient safety, and electronic health records have been identified as a high-profile contributor to the problem. This call for public comments on a draft report seeks insights on specific goals and recommended strategies to address the issue. The approaches outlined focus on reducing the time burden associated with frontline electronic health record use. The option for submitting comments is closed.
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
Clinician burnout presents challenges to organizational and patient safety. This publication summarizes survey responses from clinical leadership, health care executives, and clinicians regarding the extent of the problem and solutions to reduce its prevalence in health care. Respondents considered organizations to be accountable for improvement and they reported self-care as important to manage the impact of burnout.
Dusenbery M. New York, NY: HarperOne; 2018. ISBN: 9780062470805.
Implicit biases can affect diagnostic decision-making. This book discusses biases and cultural limitations that influence the safety of women's health care. Systemic problems are highlighted, such as lack of respect for patient concerns and insufficient biomedical research examining treatments and their effect on women.
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.
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.
Clinician burnout has recently emerged as a patient safety concern. This report from a national initiative to examine burnout provides initial insights from its work and targets areas requiring further study, such as a focus on system factors that facilitate the problem, the effect of clinician wellbeing on outcomes, and interventions to improve the clinicians' work lives.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
This report provides the insights from a panel exploring the need for transparency after a medical mistake occurs. The session discussed the history and evolution of new approaches to achieve transparency, such as communication-and-resolution programs. Experts participating in the session included Dr. David Mayer, Richard Boothman, and Helen Haskell.
Hatch S. New York, NY: Basic Books; 2016. ISBN: 9780465050642.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.