Narrow Results Clear All
- Study 1
- Book/Report 20
- Legislation/Regulation 1
- Newspaper/Magazine Article 6
- Newsletter/Journal 1
- Tools/Toolkit 3
- Web Resource
- Grant 1
- Press Release/Announcement 1
- Communication Improvement 7
- Culture of Safety 3
- Education and Training 7
- Error Reporting and Analysis 12
- Human Factors Engineering 5
- Legal and Policy Approaches 4
- Policies and Operations 1
- Quality Improvement Strategies 9
- Research Directions 2
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 20
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 2
- Identification Errors 3
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 10
- Surgical Complications 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 25
- Patients 2
- Australia and New Zealand 1
- Europe 2
- Canada 1
Search results for "Government Resource"
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.
Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Web Resource > Government Resource
Office of the National Coordinator for Health Information Technology.
Overdoses of opioid medications are considered an epidemic in the United States. This website provides access to various resources for hospitals and clinicians to help them address this patient safety concern. Sections include guidelines, clinical decision support, electronic prescribing, and prescription drug monitoring programs.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2016.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
The Institute of Medicine called for enhanced transparency in the reporting of health IT safety incidents to inform implementation and use of such technologies. This report reviews insights from a multidisciplinary task force that discussed how to design an entity focused on improving health IT–related safety that enables collaboration and learning.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.
Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information Technology; February 2015.
Rapid implementation of health information technology (IT) has presented several unanticipated safety issues. This publication explores and summarizes the current evidence around health IT and patient safety. Despite reported challenges, the authors found that health IT enhances patient safety and suggest that future research should consider the unintended consequences of health IT use, particularly the effect of human and contextual factors on implementation.
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.
This investigation found that although use of electronic health records (EHRs) in Medicare and Medicaid programs increased between 2011 and 2012, EHR systems lack the ability to track quality and safety to measure improvements. The report recommends developing a comprehensive strategy to compile clinical quality measurement data.
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013.
This white paper details how health care organizations can identify health information technology concerns and improve systems to reduce risks.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Journal Article > Government Resource
de Boer M, Boeker EB, Ramrattan MA, et al. Int J Clin Pharm. 2013;35:744-752.
Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.