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- Communication Improvement 3
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- Error Reporting and Analysis
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- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 4
- Medication Safety 12
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 5
- Health Care Executives and Administrators 25
Health Care Providers
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Search results for "Government Resource"
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Journal Article > Government Resource
Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.
Vivolo-Kantor AM, Seth P, Gladden RM, et al. MMWR Morb Mortal Wkly Rep. 2018;67:279-285.
The opioid epidemic continues unabated in the United States. Although efforts such as the 2016 Centers for Disease Control and Prevention guideline for opioid prescribing have raised awareness and changed practice, rates of opioid-related deaths are still rising. This study reports trends in emergency department visits for opioid overdose between July 2016 and September 2017. Researchers noted a nearly 30% increase in opioid overdose rates. Overdoses increased in all regions and most states, with the most prominent spikes noted in the West and Midwest. This sobering, high-quality, and timely data will inform initiatives to reduce high-risk prescribing, promote medication-assisted treatment, and improve secondary prevention of overdose. An Annual Perspective outlines strategies for mitigating opioid harms.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Journal Article > Government Resource
Guy GP Jr, Zhang K, Bohm MK, et al. MMWR Morb Mortal Wkly Rep. 2017;66:697-704.
This analysis of retail prescription data revealed that opioid prescribing has declined from a peak in 2010, but it remains higher than in 1999. Increased rates of opioid prescribing occurred in areas that are not urban, have a greater proportion of white populations, and higher unemployment and Medicaid enrollment. These results are consistent with prior studies about the opioid epidemic.
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.
Journal Article > Government Resource
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis found that common problems included drug incompatibility and drug–drug interaction. The article cautions against relying on drug ordering alerts as the sole strategy for preventing potentially harmful prescribing.
Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.
US Senate Finance Committee. December 6, 2016.
The practice of scheduling concurrent surgeries has raised concerns about increased risks of surgeon distraction, procedure delay, and insufficient expertise available in the operating room. This United States Senate report summarizes findings of an inquiry that assessed insights from 17 hospitals regarding concurrent and overlapping surgical policies. Areas of concern identified by the investigation include a lack of available data on the patient outcomes associated with the practice and need for specific billing requirements.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
Recently, diagnostic error has garnered much discussion and examination, but further research is needed to understand and track such errors. This article reviews evidence on the topic to illustrate measurement challenges and includes a sociotechnical model to identify, assess, and address diagnostic errors.
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
The National Center for Patient Safety (NCPS) has contributed to patient safety improvement initiatives in the Department of Veterans Affairs (VA) since its inception. This investigation explored VA medical centers' application of root cause analysis after adverse events and how findings from these analyses were used to make system-wide improvements. This report found that the number of root cause analyses performed has decreased and the NCPS has not yet sought to determine why, but factors such as use of other incident analysis methods may have contributed. The Government Accountability Office recommends that the VA assess reasons behind the decline in use of root cause analysis and the extent to which alternative strategies are being utilized.
Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70.
This article analyzed data on dietary errors submitted to a state reporting program and found that more than 60% of patients received trays containing food items to which they were allergic. Recommendations to prevent such errors include standardizing practices and using whiteboards as communication tools.
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
A previous report by the Veterans Affairs (VA) Office of the Inspector General found that many veterans at the Phoenix VA facility endured months-long waits for primary care appointments, due in part to inappropriate manipulation of the scheduling process so that the facility could appear to meet VA quality metrics. This follow-up report examined whether these delays led to patients experiencing preventable harm and further investigated the root causes of excessive wait times and the generalizability of the problem across the VA system. The investigators concluded that no deaths or serious harm could be directly attributed to the scheduling delays; however, the report uncovered many examples of poor quality care, including delayed diagnoses of cancer, preventable readmissions, and poor care coordination. It also appears that scheduling manipulation was rife throughout the system. The report strongly attributes the "corrosive culture" of the VA and its unresponsive leadership as major factors in the system's failure to address longstanding problems with access to care. Though the VA has achieved impressive accomplishments in providing high-quality care, the scheduling scandal has caused serious damage to its reputation. A recent commentary by Dr. Kenneth Kizer (who, as Undersecretary for Health in the VA, was widely credited for reforming the VA in the 1990s) and Dr. Ashish Jha recommends several reforms the VA should implement to transform its culture and restore its standards.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.