Narrow Results Clear All
- Communication Improvement
- Culture of Safety 2
- Education and Training 6
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 2
- Teamwork 2
- Technologic Approaches 2
- Transparency and Accountability 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 4
- Medication Safety 5
- Surgical Complications 2
- Transfusion Complications 1
Search results for "Book/Report"
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
Health care has historically treated data as something to be safeguarded rather than openly discussed. Even in the information age it is difficult for patients to access their own medical records and for clinicians to obtain data on their own clinical performance, and efforts to encourage public reporting of safety and quality data remain controversial. This report by the Lucian Leape Institute of the National Patient Safety Foundation strongly advocates for improving transparency in health care. The authors identify four key domains of transparency and ways in which they could be enhanced: transparency between clinicians and patients (by promoting error disclosure), transparency among clinicians themselves (through peer review processes), transparency of health care organizations with one another (using collaborative approaches to improving care), and transparency with the public (by publicly reporting quality and safety data). The report includes a series of specific recommendations for clinicians, health care organizations, and governmental and nongovernmental leadership to enhance transparency. The authors acknowledge that a robust culture of safety is essential in order to overcome barriers to the free flow of information. Prior reports from the Lucian Leape Institute have addressed the role of quality and safety in health professions education and the role of information technology in patient safety.
Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July 2014. NIHCR Research Brief No. 17.
According to this report, many vendors are still working to add and implement enhanced functions for electronic health records to support medication reconciliation capabilities. Health care workers are instead employing hybrid paper-electronic processes to ensure patients' medication lists remain accurate throughout their hospital stay.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
This e-book provides tips for incorporating activities into daily hospital practice in conjunction with the 2013 National Patient Safety Goals.
Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.
Silence Kills was a 2005 report that highlighted communication failures that contribute to patient harm. These included broken rules, poor teamwork, and disruptive behaviors. This report builds on those findings based on a survey of more than 6500 nurses and nurse managers. Key findings suggested that existing safety tools, such as checklists, are not in themselves solutions to these communication failures. Nurses identified dangerous shortcuts, incompetence, and disrespect as three concerns that undermine systems designed to provide safer care. A past AHRQ WebM&M perspective and interview discuss the role of checklists in health care settings.
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.
Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.
This guide introduces strategies for hospital managers to prevent avoidable readmissions.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.
This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Oakbrook, IL: Joint Commission Resources; 2008. ISBN: 9781599400921.
This book describes various team training initiatives, specific strategies for team development, and case studies to illustrate successful improvement techniques.