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Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Journal Article > Review
Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Med Care Res Rev. 2009;66(suppl 6):90S-119S.
Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.
Journal Article > Study
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
This case study examines an organizational response to a serious adverse event—a medication error in the intensive care unit that caused serious patient harm. Although a root cause analysis (RCA) was eventually convened, resulting in implementation of a systematic solution, prior to the RCA each professional group involved (nurses, pharmacists, and physicians) had already decided on individual approaches and solutions to the error. This resulted in unnecessary conflict and delays in reaching a workable solution to the problem.
Journal Article > Study
Chang Y, Mark B. Nurs Res. 2011;60:32-39.
The direct relationship between registered nurse staffing and the safety of inpatient care is supported by a large body of literature. In addition to staffing ratios, safety culture has also been found to be a determinant of errors. This study explored the links between nurse staffing, safety culture, and medication errors, and found evidence for a complex relationship. The learning climate (a component of safety culture that measures communication between providers) was directly correlated with medication error rate, and also appeared to interact with staffing ratios. Nursing units with a negative learning climate reported more medication errors if they were also staffed by a lower proportion of registered nurses. An Institute of Medicine report called for improving patient safety by addressing cultural factors, including learning climate, that negatively influence nurse working conditions.