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- Device-related Complications 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems
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Search results for "Medicine"
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Tools/Toolkit > Government Resource
Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement.
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
This toolkit provides resources to help augment testing processes in ambulatory care settings, including tools for identifying areas of concern and measuring improvements.
Davis K, Collier S, Situ J, Coe M, Cleary-Fishman M. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.
This analysis found that scheduling problems among patients seeking primary care from Veterans Affairs health systems continue to occur. The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary care and spotlights the need to develop and disseminate a comprehensive policy for Veterans Affairs schedulers to reduce risk of scheduling errors.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Francis R. London, UK: Freedom to Speak Up Review; February 2015.
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.
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.
Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.
This report analyzes the literature discussing emergency department discharge processes and highlights elements of high-quality discharges and risk factors for suboptimal discharges. The in-depth review summarizes interventions currently implemented to augment discharge procedures, care coordination, and the identification of patients more susceptible to poor discharge.
Audiovisual > Audiovisual Presentation
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014). (Testimony of Richard Griffin; Robert A. McDonald.)
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
A previous report by the Veterans Affairs (VA) Office of the Inspector General found that many veterans at the Phoenix VA facility endured months-long waits for primary care appointments, due in part to inappropriate manipulation of the scheduling process so that the facility could appear to meet VA quality metrics. This follow-up report examined whether these delays led to patients experiencing preventable harm and further investigated the root causes of excessive wait times and the generalizability of the problem across the VA system. The investigators concluded that no deaths or serious harm could be directly attributed to the scheduling delays; however, the report uncovered many examples of poor quality care, including delayed diagnoses of cancer, preventable readmissions, and poor care coordination. It also appears that scheduling manipulation was rife throughout the system. The report strongly attributes the "corrosive culture" of the VA and its unresponsive leadership as major factors in the system's failure to address longstanding problems with access to care. Though the VA has achieved impressive accomplishments in providing high-quality care, the scheduling scandal has caused serious damage to its reputation. A recent commentary by Dr. Kenneth Kizer (who, as Undersecretary for Health in the VA, was widely credited for reforming the VA in the 1990s) and Dr. Ashish Jha recommends several reforms the VA should implement to transform its culture and restore its standards.
Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
London, UK: Parliamentary and Health Service Ombudsman; June 24, 2014.
This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
Infants discharged from the neonatal intensive care unit to home are particularly vulnerable to care coordination errors. This four-component toolkit includes materials to help hospitals implement a coach program to educate providers and families about common communication and health concerns that arise during this transition.
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.
This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
Tools/Toolkit > Government Resource
Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; September 2015. AHRQ Publication No. 12(13)-0084.
This toolkit provides information to help hospitals implement Project RED, including how to determine goals at the outset and measure project outcomes after implementation.