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Search results for "Physicians"
National Patient Safety Agency, the Medical Defence Union and Medical Protection Society. London, England: NPSA; 2005
This two-part report focuses on the experience of committing a medical error, along with strategies to reduce future events. The first part provides a series of shared stories from clinicians who discuss their personal experiences in making medical errors. The second part uses six case studies of errors as a background for expert analysis and discussion. The report also provides a motivation for reporting by explaining the benefits that come from such vigilance and how changing systems can lead to improved safety.
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.
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.
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
Clinician burnout presents challenges to organizational and patient safety. This publication summarizes survey responses from clinical leadership, health care executives, and clinicians regarding the extent of the problem and solutions to reduce its prevalence in health care. Respondents considered organizations to be accountable for improvement and they reported self-care as important to manage the impact of burnout.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Manchester, UK: General Medical Council; November 2014.
Manchester, UK: General Medical Council; November 2014.
London, UK: General Medical Council; November 2013.
This publication analyzes patient safety concerns reported by physicians in training in the United Kingdom.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Trew M, Nettleton S, Flemons W. Edmonton, AB, Canada: Canadian Patient Safety Institute; June 2012.
This publication describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organizations to enable such collaboration.
Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study.
Avery T, Barber N, Ghaleb M, et al. London, UK: General Medical Council; May 2, 2012.
Examining prescription errors in general practices in England, this report suggests that information technology and incident reporting could address issues that persist since an earlier study.
Manchester, UK: General Medical Council; January 2012. ISBN: 9780901458568.
This guidance from the United Kingdom outlines how physicians can raise concerns and take appropriate action if they believe a patient's safety is at risk.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2012. Report No. OEI-06-09-00091.
Incident reporting systems are ubiquitous, but their effectiveness as a means of monitoring for patient safety problems is unclear. In a prior report, the Office of the Inspector General (OIG) found that 13.5% of Medicare beneficiaries suffered an adverse event while hospitalized. This follow-up analysis found that incident reports were not filed for the vast majority of these adverse events. Moreover, hospital personnel did not voluntarily report any of the never events identified in the earlier study. The reasons for this lack of reporting likely include confusion about which types of errors needed to be reported, as well as other issues documented in prior studies such as lack of reporting by physicians. Based on these findings, the OIG recommends that the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services (CMS) create a uniform list of potentially reportable events for dissemination to hospitals, and that CMS should assist accrediting agencies in assessing the adequacy of hospitals' error reporting systems.
Lorincz CY, Drazen E, Sokol PE, et al. Chicago, IL: American Medical Association; 2011.
Although traditionally the majority of patient safety efforts have focused on inpatient care, the overwhelming bulk of health care actually takes place in the ambulatory setting. Accordingly, the scope of widespread documented adverse events among outpatients is vast. Updating a previous report, this publication analyzes efforts to improve patient safety in ambulatory care over the past decade and identifies gaps that future research should address. Dr. Richard Baron discusses patient safety in the office setting in an AHRQ WebM&M perspective.
Women's Health Care Physicians; Committee on Patient Safety and Quality Improvement. Washington, DC: American College of Obstetricians and Gynecologists; 2010. ISBN: 9781934946930.
This manual describes various facets of health care quality and tools for quality improvement in obstetric and gynecologic practice.
Thomas MO, Quinn CJ, Donohue GM. Sudbury, MA: Jones Bartlett; 2009. ISBN: 100763748560.
Written by experts in legal medicine and patient safety, this comprehensive book covers key issues surrounding medical malpractice for practicing physicians, trainees, and risk managers.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
This report suggests that a systems approach to child social services in Great Britain would facilitate a fair and open culture and encourage learning from near misses.
Berlinger N. Baltimore, MD: Johns Hopkins University Press; 2005. ISBN: 0801881676.
The author draws from theological, ethical, religious, and cultural foundations to understand the actions that should be taken after a medical mistake.