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- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis 9
- Human Factors Engineering 1
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- Quality Improvement Strategies 1
- Teamwork 1
- Transparency and Accountability
Search results for "United States of America"
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.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.
Washington, DC: America's Health Insurance Plans; 2018.
Oakbrook Terrace; IL: Joint Commission; 2017.
The Joint Commission annual report provides performance data for United States hospitals across a range of accountability measures and highlights changes associated with quality measurement. In 2016, hospital performance on accountability measures remained strong. Although the composite accountability score decreased slightly, this result is thought to be due to the fact that measures were retired that had high performance in the past. In 2016, 59.6% of hospitals achieved overall composite performance of greater than 95%. The report also describes the Pioneers in Quality program, which was designed to facilitate hospital reporting of electronic clinical quality measures. In 2016, 470 hospitals reported electronic clinical quality measure data compared to only 34 in 2015. In a PSNet interview, the president and chief executive officer of The Joint Commission discusses high reliability in health care.
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
Washington, DC: United States Government Accountability Office; October 2017. Publication GAO-18-15.
Opioid prescribing is under increased scrutiny in an effort to address opioid misuse. Examining Medicare Part D prescription trends, this report recommends that the Centers for Medicare and Medicaid Services collect more data on beneficiaries receiving high doses of opioids and the clinicians who prescribe them and advocates for increased reporting of clinicians who inappropriately prescribe opioids. An Annual Perspective discussed the opioid epidemic as a patient safety problem.
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
This report provides the insights from a panel exploring the need for transparency after a medical mistake occurs. The session discussed the history and evolution of new approaches to achieve transparency, such as communication-and-resolution programs. Experts participating in the session included Dr. David Mayer, Richard Boothman, and Helen Haskell.
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
Health care has historically treated data as something to be safeguarded rather than openly discussed. Even in the information age it is difficult for patients to access their own medical records and for clinicians to obtain data on their own clinical performance, and efforts to encourage public reporting of safety and quality data remain controversial. This report by the Lucian Leape Institute of the National Patient Safety Foundation strongly advocates for improving transparency in health care. The authors identify four key domains of transparency and ways in which they could be enhanced: transparency between clinicians and patients (by promoting error disclosure), transparency among clinicians themselves (through peer review processes), transparency of health care organizations with one another (using collaborative approaches to improving care), and transparency with the public (by publicly reporting quality and safety data). The report includes a series of specific recommendations for clinicians, health care organizations, and governmental and nongovernmental leadership to enhance transparency. The authors acknowledge that a robust culture of safety is essential in order to overcome barriers to the free flow of information. Prior reports from the Lucian Leape Institute have addressed the role of quality and safety in health professions education and the role of information technology in patient safety.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
St. Paul, MN: Minnesota Department of Health; January 2009.
Through a qualitative evaluation of the Minnesota statewide reporting initiative, this report suggests ways to improve the reporting system to facilitate continued learning and transparency.
Davenport TH, Prusak L. Boston, MA: Harvard Business School Press; 1998. ISBN: 0875846556.