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Search results for "Organizational Policy/Guidelines"
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Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. December 10, 2018;(60):1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Journal Article > Commentary
Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA.
Middleton B, Bloomrosen M, Dente MA, et al. J Am Med Inform Assoc. 2013;20:e2-e8.
The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.