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- Review 1
- Study 2
- Slideset 2
- Legislation/Regulation 16
- Special or Theme Issue 6
- Glossary 1
- Toolkit 19
- Web Resource 238
- Award 2
- Bibliography 2
- Grant 1
- Meeting/Conference 21
- Press Release/Announcement 1
Communication between Providers
- Sbar 1
- Communication between Providers 50
- Culture of Safety 158
Education and Training
- Students 3
Error Reporting and Analysis
- Never Events 20
- Error Reporting 141
Human Factors Engineering
- Checklists 13
Legal and Policy Approaches
- Regulation 23
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- Policies and Operations 10
Quality Improvement Strategies
- Benchmarking 40
- Research Directions 4
- Specialization of Care 17
- Teamwork 44
- Clinical Information Systems 42
- Transparency and Accountability 15
- Device-related Complications 18
- Diagnostic Errors 29
- Discontinuities, Gaps, and Hand-Off Problems 51
- Drug shortages 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 6
- Identification Errors 15
- Interruptions and distractions 2
- Medical Complications 84
- Medication Errors/Preventable Adverse Drug Events 63
- Nonsurgical Procedural Complications 12
- Overtreatment 3
- Psychological and Social Complications 37
- Second victims 2
- Surgical Complications 58
- Transfusion Complications 3
- Ambulatory Care 91
- General Hospitals 53
- Long-Term Care 18
- Outpatient Surgery 10
- Patient Transport 1
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- Allied Health Services 2
- Geriatrics 11
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- Internal Medicine 183
- Nursing 25
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- Family Members and Caregivers 17
- Health Care Executives and Administrators 651
Health Care Providers
- Nurses 28
- Pharmacists 16
- Physicians 61
Non-Health Care Professionals
- Educators 43
- Engineers 20
- Media 9
- Policy Makers 160
- Patients 100
- Africa 2
- Australia and New Zealand 11
- United Kingdom 140
- Canada 26
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 141
- United States Federal Government 183
Search results for ""
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School; September 2018. ISBN: 9781909029880.
Regulation and accreditation programs are controversial approaches to improve safety. This report provides a framework developed to analyze the quality improvement inspection process in the United Kingdom. Investigators applied eight factors to examine how regulation can result in care delivery changes. They found that the regulation process can help engage staff in identifying areas of concern and uncover issues like poor performance.
Patient Safety Learning: London, UK; September 2018.
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report outlines existing challenges and strategies to drive system improvement, including leadership engagement, shared learning, patient safety data optimization, and building on expertise from other high-risk industries.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Medication safety is a concern in various settings across an organization. This white paper discusses the role of a medication safety officer to oversee reporting and analysis of medication errors and coordinate improvement efforts. Responsibilities of a medication officer include serving as a champion, advocating for safety interventions, and helping implement system changes.
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Mannion R, Blenkinsopp J, Powell M, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
Staff willingness to speak up about safety and process concerns enables organization and practice improvements that prevent patient harm. This review explores challenges to raising concerns in the National Health Service and discusses policies that support whistleblowers. Further research is needed to examine organizational failures when concerns are reported.
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018. ISBN: 9780309474290.
Health literacy affects patients' ability to comprehend information about their health and participate effectively with clinicians to ensure their care is safe, appropriate, and effective. This workshop report summarizes discussions about health literacy programs and provides case studies of health organizations that have adopted such programs. A PSNet perspective discusses the intersection of patient safety and health literacy.
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
Both organizational and individual accountability are required to ensure safe care. This analysis of Department of Veterans Affairs (VA) responses to whistle-blower concerns and reports of staff misconduct found that the VA has procedures for investigating these allegations but determined that the process was unreliable. The report outlines recommendations for improvement including ensuring whistle-blowers are treated fairly and assigning responsibilities across the hierarchy to ensure incidents receive the appropriate attention.
Boston, MA: Institute for Healthcare Improvement; 2018.
The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence assessment to provide recommendations to improve the safety of home-based care. The document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered care, safety culture, learning and improvement systems, team-based and coordinated care provision, and incentive models.
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. This report explored staffing levels in United Kingdom trusts for three tiers of expertise and found them to be inadequate across the system. The paper provides recommendations for staffing decisions for individual organizations and emphasizes the need for improved focus on care provision during routine working hours to support a healthy work force and safe patient care.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
Hospital patient and family advisory councils can help inform development of patient-centered safety initiatives. This report discusses characteristics of hospital-based patient and family advisory councils in the state of New York and outlines best practices for implementation to engage patients and families in quality and safety improvement.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.