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Search results for "Active Errors"

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Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Journal Article > Commentary

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

Henriksen K, Dymek C, Harrison MI, Brady JP, Arnold SB. Diagnosis. 2017 May 23; [Epub ahead of print].

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Journal Article > Study

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

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.

Tools/Toolkit > Fact Sheet/FAQs

Four Medication Safety Tips for Older Adults.

FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; September 20, 2016.

Highlighting how aging affects medication absorption that may lead to complications, this fact sheet offers recommendations for older patients to follow instructions, maintain a medication list, be aware of drug interaction potential, and perform an annual review of medications with clinicians to help them take prescriptions safely.

Book/Report

Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Audiovisual

Making health care safer. Think sepsis. Time matters.

CDC Vital Signs. August 23, 2016.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Tools/Toolkit > Government Resource

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit.

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

Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, and teaching materials, and it has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.

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.

Press Release/Announcement

FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 4, 2016.

This announcement alerts prescribers to differences in two oral formulations of the same medication that can lead to dosing errors. The FDA suggests that clinicians specify dosage form, strength, and frequency on prescriptions for this drug to reduce the risk of patient harm and recommend that pharmacists follow up with prescribers if such information is missing.

Journal Article > Study

Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration.

Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. J Am Geriatr Soc. 2015;63:1601-1607.

This health system performance study ranked sites within the Veterans Affairs health system using two measures of potentially inappropriate prescribing in older veterans. Researchers found that sites ranked similarly when they used new potentially inappropriate medications to measure performance compared to when they used existing potentially inappropriate medications as the measure. These results suggest that measuring new potentially inappropriate prescriptions is a feasible strategy worthy of further study.

Legislation/Regulation

Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.

Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.

Heparin is a high-alert anticoagulant that has been associated with patient harm due to issues with administration and contamination. This draft guidance seeks to engage insights from the field to help improve labeling practices. The deadline for officially submitting comments was October 7, 2015.

Newspaper/Magazine Article

FDA begins inquiry after death and illness from saline bags meant for training.

Tavernise S. New York Times. January 15, 2015.

This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.

Book/Report

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.

A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.

Journal Article > Study

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.

Al-Mutairi A, Meyer AND, Chang P, Singh H. J Am Coll Radiol. 2015;12:385-389.

This examination of abnormal imaging results found that patients recommended for additional imaging were often lost to follow-up. Because lack of timely follow-up can lead to delays in diagnosis, this work highlights a gap in current patient safety practices.

Tools/Toolkit > Fact Sheet/FAQs

Explicit and Standardized Prescription Medicine Instructions.

Rockville, MD: Agency for Healthcare Research and Quality; December 2014.

Standardization has been embraced as a strategy to improve health literacy and to reduce patient misunderstanding of medication instructions. This tool provides standard language that clarifies directions for patients regarding when they should take their medications.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.

Elwy AR, Bokhour BG, Maguire EM, et al. J Gen Intern Med. 2014;29(suppl 4):895-903.

This interview study examined how the Veterans Affairs medical centers disclosed large-scale adverse events to stakeholders. These incidents impacted multiple patients and included system failures as well as errors by individuals. Interviews with frontline staff, local leadership, and affected patients and family members examined strengths and weakness of the current disclosure process and elicited input for improvement. All stakeholders reinforced the need for tailored, interactive, multi-modal communication rather than standard mailed letters. While staff expressed the concern that adverse event disclosure led to loss of trust, patients and families stated that despite their initial distress they supported disclosure and follow-up care associated with large-scale adverse events. These findings are consistent with prior studies of error disclosure, but demonstrate a gap in frontline staff understanding of the rationale for disclosure.

Special or Theme Issue

From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.

This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.

Book/Report

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.

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