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Approach to Improving Safety
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Search results for "Active Errors"

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Meeting/Conference > Government Resource

AHRQ Research Summit on Improving Diagnosis in Health Care.

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Journal Article > Study

A framework to assess patient-reported adverse outcomes arising during hospitalization.

Barbara O, Jose SM, Jayna HL, et al. BMC Health Serv Res. 2016;16:357.

Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.

Journal Article > Review

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

Green B, Parry D, Oeppen RS, Plint S, Dale T, Brennan PA. Oral Dis. 2016 Jul 22; [Epub ahead of print].

Situational awareness during critical incidents is a key component of teamwork. This review spotlights the importance of situational awareness in health care and provides information about how to assess and develop it in individual clinicians and among team members.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Commentary

The problem with root cause analysis.

Peerally MF, Carr S, Waring J, Dixon-Woods M. BMJ Qual Saf. 2017;26:417-422.

Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health care. Discussing weaknesses associated with using RCAs, this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis quality, and insufficient feedback should be addressed to enhance the effectiveness of RCAs and sustain organizational learning from failure.

Book/Report

Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition.

Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.

Lean methodology focuses on establishing a culture that supports employee safety and drives process improvement. This book provides information about Lean and how to implement such concepts to integrate quality and safety behaviors in health care delivery. One chapter focuses on the use of root cause problem-solving and error prevention. The author spoke about applying Lean in hospitals in a previous PSNet interview .

Book/Report

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.

Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

Journal Article > Commentary

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

Robinson SN, Neyens DM, Diller T. Am J Med Qual. 2017;32:285-291.

There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.

Journal Article > Commentary

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change.

Clifford SP, Mick PB, Derhake BM. J Investig Med High Impact Case Rep. 2016;4:2324709616647746.

Transfusion errors can have serious consequences. This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews findings of the subsequent root cause analysis, which determined training weaknesses, time pressures, and distractions within the team due to the chaotic nature of trauma care.

Journal Article > Commentary

'Just culture': improving safety by achieving substantive, procedural and restorative justice.

Dekker SWA, Breakey H. Saf Sci. 2016;85:187-193.

A just culture balances organizational context with appropriate accountability after an error. This commentary outlines moral and safety issues that just culture approaches should address to build trust for blame-free response to error and enable learning from failure.

Web Resource > Government Resource

Betsy Lehman Center for Patient Safety and Medical Error Reduction.

Center for Health Information and Analysis.

The Betsy Lehman Center is an independent organization named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.

Journal Article > Commentary

Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

McTiernan P, Wachter RM, Meyer GS, Gandhi TK. BMJ Qual Saf. 2015;24:162-166.

Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.

Journal Article > Study

Blink or think: can further reflection improve initial diagnostic impressions?

Hess BJ, Lipner RS, Thompson V, Holmboe ES, Graber ML. Acad Med. 2015;90:112-118.

This direct observation study examined cognition among experienced clinicians in the setting of their recertification examination and found that when they changed answers, it was usually from an incorrect to a correct response. This suggests that further reflection enhances accuracy compared to intuitive response, consistent with work on metacognition to enhance diagnostic accuracy.

Book/Report

GMC National Training Survey 2014: Concerns About Patient Safety.

Manchester, UK: General Medical Council; November 2014.

This report summarizes concerns reported in an annual survey of junior doctors in the United Kingdom, reviews how these issues have been addressed, and uses case studies to illustrate the role of reporting systems in tracking perceived patient safety hazards.

Journal Article > Commentary

Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

Upadhyay DK, Sittig DF, Singh H. Diagnosis (Berl). 2014;1:283.

Misdiagnosis and errors linked to electronic health records (EHRs) are common concerns in patient safety. This commentary examines these elements in the context of the first Ebola case in the United States to reveal weaknesses in emergency department care, disaster management, and diagnostic processes. The case analysis highlights challenges associated with forming diagnoses and the usability of EHRs as decision support tools.

Journal Article > Commentary

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

Ratwani RM, Fong A. J Am Med Inform Assoc. 2015;22:312-317.

This commentary describes the design and development of hospital-level and system-level dashboards representing data from patient safety event reporting systems as a way to reduce the burden of analyzing internal incident reports, increase awareness of adverse event trends, and enable utilization of the data to inform improvement.

Journal Article > Study

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.

O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. Age Ageing. 2015;44:213-218.

This consensus guideline describes expanded criteria to identify inappropriate medication prescribing for older patients. This strategy can address high rates of adverse drug events in older populations, especially if integrated into clinical decision support.

Journal Article > Study

Systematic biases in group decision-making: implications for patient safety.

Mannion R, Thompson C. Int J Qual Health Care. 2014;26:606-612.

Cognitive approaches to patient safety have mostly focused on individual decisions. This study instead examines group decision-making and its safety implications. The authors describe four pitfalls associated with group decisions: groupthink in which the strongly connected mentality of members hinders dissenting opinion; social loafing in which people expend less effort because of a perceived failure to obtain individual credit for efforts; group polarization in which individual moderate positions are subsumed by more extreme or effort intensive group decisions; and escalation of commitment in which a poor outcome following a significant investment results in further commitment of resources instead of exploring a new approach. These four concepts can serve as a theoretical framework for future empiric work to characterize and improve group decision-making as an aspect of safety culture.

Journal Article > Study

Time of day and the decision to prescribe antibiotics.

Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014;174:2029-2031.

Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.

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