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- Communication Improvement 2
- Culture of Safety 4
- Education and Training 4
- Error Reporting and Analysis 14
- Legal and Policy Approaches 7
Quality Improvement Strategies
- Audit and Feedback
- Specialization of Care 1
- Technologic Approaches 1
- Health Care Executives and Administrators 24
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 14
- Patients 2
Search results for "Audit and Feedback"
- Audit and Feedback
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
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.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Jefferson City, MO: Center for Patient Safety; June 11, 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report analyzes trends present in reports submitted to the PSO in 2018. Medication errors, falls, and health care–acquired infections were frequently reported. The material discusses reasons for these events, shares lessons learned, and points to resources to aid organizations in reducing conditions that enable reportable occurrences.
Leeds, UK: Health and Social Care Information Centre; 2018.
This report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and Wales.
VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.
Washington, DC: United States Government Accountability Office; October 28, 2011. Publication GAO-12-6R.
This report reviews injury claim data to assess quality of care in the Veterans Affairs health system.
Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9781845621636.
Analyzing health care failures from 2004-2007 in the United Kingdom, this report identifies common themes and addresses how such investigations can guide improvement recommendations.
Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The RAND Corporation;2005. ISBN: 0833037870.
The authors report on the history of Agency for Healthcare Research and Quality's (AHRQ) involvement in patient safety, recap AHRQ's activities through September 2003, and provide suggestions for future actions. This document is the first of four yearly reports funded by AHRQ to assess their work.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
Prior research has shown that safety culture is relatively poor among frontline workers in skilled nursing facilities. Trigger tools can help to identify opportunities for patient harm and measure adverse events that occur over time. This toolkit outlines steps to use a trigger tool in skilled nursing facilities, reviews types of events that take place in this setting, and discusses how to analyze trigger tool data to inform improvement work. A past WebM&M commentary discusses challenges to safety in long-term care.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.
This publication reports recommendations from a focus group exploring the utility of health information technology in enhancing quality measurement and discusses how the data can be used to improve care.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
Thomson R, Luettel D, Healey F, Scobie S. London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634055.
In analyzing information submitted to the British voluntary incident reporting system, this report revealed safety problems that contributed to delays in treatment and resuscitation.
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).
Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The Rand Corporation; 2007. ISBN: 9780833041487.
This report is the second installment of a series commissioned to evaluate the success of the Agency for Healthcare Research and Quality's patient safety agenda and related programs.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.