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Search results for ""
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 978-0190665395.
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to uncertainty, bias, and overconfidence that hinder accurate image assessment. Discussing the scope and impact of human error in diagnostic radiology, this book explores the future of advanced information technologies in diagnostic radiology and provides recommendations to reduce the effect of human fallibility on imaging interpretation.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.
Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019.
Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers.
Horsham, PA: Institute for Safe Medication Practices; January 2019.
Inaccurate or incomplete data in electronic health records can limit the effectiveness of health information technology. This guideline focuses on improvements in how medication information is formatted to support safe medication delivery. Recommended approaches include avoidance of error-prone abbreviations, use of Tall Man lettering, and required use of metric measurements to reduce risks in electronic health records, barcoding systems, smart infusion devices, and other information technologies.
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Burnout can diminish the safety of clinicians, students, health care workers, and patients. This report suggests institutions apply design thinking and systems thinking methods to develop interventions to reduce burnout and stress. A past Annual Perspective covered the impact of burnout on patient safety.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
This guidance summarizes the current status of global patient safety, highlights World Health Organization efforts to address the problem, and provides direction for WHO leadership and policy makers to achieve improvements in safety. Recommendations include universal health coverage, coordination of efforts, and dissemination of effective practices.