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- Study 1
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- Special or Theme Issue 2
- Toolkit 1
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- Communication Improvement 27
- Culture of Safety 20
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 22
- Human Factors Engineering 16
- Legal and Policy Approaches 16
- Logistical Approaches 4
- Quality Improvement Strategies 51
- Research Directions 1
- Specialization of Care 4
- Teamwork 9
- Clinical Information Systems 6
- Device-related Complications 7
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 11
- Drug shortages 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 19
- Medication Errors/Preventable Adverse Drug Events 14
- Nonsurgical Procedural Complications 5
- Overtreatment 1
- Psychological and Social Complications 3
- Surgical Complications 9
- Internal Medicine 26
- Surgery 5
- Nursing 4
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- Family Members and Caregivers 1
Health Care Executives and Administrators
- Quality and Safety Professionals
Health Care Providers
- Nurses 5
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Non-Health Care Professionals
- Media 2
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- Australia and New Zealand 1
- Europe 24
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 25
- United States Federal Government 35
Search results for "Quality and Safety Professionals"
- Quality and Safety Professionals
The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary Report.
Hanlon C, Rosenthal J. Washington, DC: National Academy for State Health Policy; 2007.
This report summarizes a September 2007 symposium that brought together patient safety officials from 11 states. The meeting examined existing and emerging issues and also provided participants with policy solutions based on strategies successfully implemented in Pennsylvania.
CHPSO: Sacramento, CA; 2019.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2018 trends, activities, and outcomes of initiatives at a 10-state PSO. Sections of the report include high-level review of reported medication and perinatal events, safe table data analysis, and strategies to improve incident reporting.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
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.
Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in the nursing home setting. The 2016 user comparative database report summarizes survey data obtained from 12,395 staff and provider respondents working in 209 nursing homes. The report highlights two areas of safety culture in which nursing homes appear to do well: overall perceptions of resident safety and feedback and communication about incidents. Areas identified as needing improvement across most nursing homes included staffing issues and ensuring a nonpunitive response to mistakes. A previous PSNet perspective provided insights on safety culture.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.
Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.
Despite the reduction of drug shortages in recent years, access to certain types of drugs, such as generic sterile injectable medications, remains limited. Analyzing data on drug shortages in the United States, this government report identifies factors that contribute to shortages and suggests prioritizing efforts to address the most pressing problems including suppliers that fail to comply with standards.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Manchester, UK: General Medical Council; November 2014.
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Washington, DC: Association of American Medical Colleges; 2014.
Studies have revealed a gap between what residents are expected to know and how prepared new interns are when they begin residency training, raising concern about patient safety during this period. These guides provide information for both faculty and students about key competencies that should be expected of new residents on their first day.
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.