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Search results for "Latent Errors"
Journal Article > Commentary
Judson TJ, Press MJ, Detsky AS. Healthc (Amst.). 2019;7:4-6.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Journal Article > Study
Kozhimannil KB, Sommerness SA, Rauk P, et al. Jt Comm J Qual Patient Saf. 2013;39:339-348.
An inconvenient truth about the patient safety movement is that in many cases hospitals actually profit when errors occur. A recent study found that hospitals received greater net reimbursements for patients who experienced surgical complications compared with patients whose surgeries were uncomplicated. This study examined the financial impact of an effort to eliminate obstetric complications in a five-hospital health system. The project led to an 11% reduction in preventable adverse events, but hospital reimbursements decreased considerably as a result—meaning that although costs were saved, the hospitals' net revenues declined overall. This finding represents a classic case of misaligned incentives: the outcome was beneficial for payers and patients (who received higher quality care at lower cost) but not directly beneficial for hospitals (who shouldered the cost of implementing the intervention but lost revenue as a result). As the return on investment for safety interventions such as computerized provider order entry is marginal at best, payment system reform to align incentives will be necessary in order to improve the business case for safety.
Journal Article > Study
Sharif I, Tse J. Pediatrics. 2010;125:960-965.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.