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- Research Directions 1
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- Device-related Complications 1
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- Drug shortages 3
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- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications 1
- Allied Health Services 1
- Internal Medicine 19
- Surgery 2
- Nursing 4
- Pharmacy 4
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- Health Care Executives and Administrators 60
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Search results for "Latent Errors"
- Latent Errors
Dekker S. Aldershot, UK: Ashgate Publishing; 2014. ISBN: 9781472439048.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
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.
Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.
Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447.
Despite great effort, health care organizations are still learning how to identify safety problems, especially with regard to proactively detecting latent errors before patients are harmed. Prior studies have shown that no single method can unearth all safety problems within an organization, forcing leaders to rely on multiple complementary sources of data. In this report, the authors present a framework for developing a comprehensive picture of safety at the organizational level. Drawing on principles used by high reliability organizations in other industries, the framework encompasses five domains of safety: past harm (retrospectively identifying safety issues, such as through incident reports), reliability (ensuring adherence to appropriate processes of care), sensitivity to operations (prospectively identifying safety problems), anticipation and preparedness (maintaining safety culture and using checklists to avert common complications), and learning from safety events. The lead author of the report, Prof. Charles Vincent, was interviewed by AHRQ WebM&M in 2012.
Woods DD, Dekker S, Cook R, Johannesen L, Sarter N. Burlington, VT: Ashgate; 2010. ISBN: 9780754678335.
"Human error," the authors of this book argue, is an inherently misleading term. Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Merry A, Smith AM. Cambridge, England: Cambridge University Press; 2001.
Merry, a New Zealand anesthesiologist, and Smith, a legal educator and a popular writer, explore the nature of medical errors. The authors suggest that most errors are due to systems factors, not moral lapses, and thus the tort system, which focuses on assigning individual blame, is an imperfect tool for dealing with these errors. The authors also summarize situations in which blame is appropriate and present concepts to help the reader discern the difference. This book will help readers understand the nature of medical error and the role of the legal system in patient safety.
Reason JT. Aldershot, Hampshire, England: Ashgate; 1997.
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest and illustrates many of the key concepts that ultimately formed the core of the patient safety movement. Much of Lucian Leape's work in Error in Medicine involved translating Reason's concepts into health care applications. In this seminal book, readers are introduced to the now-famous "Swiss cheese model" of errors in high-risk enterprises, the difference between active and latent errors, the difference between "slips" and "mistakes," the importance of a safety culture, the role of regulation, training and incentives, and much more. This book provides a good introduction to safety and systems theory.
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.
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.
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.
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
Complex systems are prone to failure. This book provides a multi-industry discussion of factors that contribute to failure. The authors highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure, and poorly designed safety strategies can unintentionally contribute to harm. Recommended strategies to manage risks include those utilized in patient safety work, such as multidisciplinary teamwork, process design, and systems thinking.
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.
Scoville R, Little K, Rakover J, Luther K, Mate K. Cambridge, MA: Institute for Healthcare Improvement; 2016.
Numerous activities and programs have been launched to improve patient safety, but sustaining improvements can be challenging. This white paper provides a framework that draws from key quality improvement concepts and Lean management tactics to help organizations integrate safety improvements in clinicians' daily work over time.
Communicating Radiation Risks in Paediatric Imaging: Information to Support Healthcare Discussions About Benefit and Risk.
Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241510349.
Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940446387.
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. This workshop report reveals how health literacy affects patients' abilities to follow discharge instructions and makes recommendations to improve after-visit summaries to augment patient understanding of directions.
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.