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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.
Journal Article > Study
Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.
Murphy DR, Meyer AND, Vaghani V, et al. J Am Coll Radiol. 2018;15:287-295.
Electronic triggers are critical tools for detecting adverse events, diagnostic errors, and other safety hazards. Researchers developed an electronic health record–based trigger tool to identify delays in abnormal mammogram follow-up at Veterans Affairs facilities. The tool was moderately effective in detecting diagnostic and treatment delays (positive predictive value 71%) and rarely failed to identify a delay (negative predictive value 93%). Inability to schedule timely follow-up and other systems issues were the most common sources of delay. This study is a rigorous example of how trigger tools can detect safety hazards and improve timely cancer diagnosis. A recent Annual Perspective describes how electronic health records can both help and hinder patient safety.
Journal Article > Study
Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.
Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.
Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.
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.
Journal Article > Review
Jackson PD, Biggins MS, Cowan L, French B, Hopkins SL, Uphold CR. Rehabil Nurs. 2016;41:135-148.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Journal Article > Study
"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.
Bergman AA, Flanagan ME, Ebright PR, O'Brien CM, Frankel RM. BMJ Qual Saf. 2016;25:84-91.
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.
Journal Article > Study
Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. J Am Med Inform Assoc. 2014;21:1053-1059.
Health information technology is being rapidly utilized in the clinical environment, with recent data showing that most hospitals and clinics have implemented some form of electronic health record (EHR). In this context, this report from the Veterans Health Administration's Informatics Patient Safety Office is timely, as it uses a sociotechnical framework that takes into account both technical aspects and human factors engineering principles to analyze 100 safety incidents relating to the EHR. The authors found four categories of system flaws: mismatches between user needs and information displays, errors arising from software modification or updates, failures at the interface between the EHR and other clinical systems, and hidden dependencies within the system itself. Most of these issues were identified long after the EHR was implemented, highlighting the need for ongoing monitoring and optimization of EHRs to ensure their safety capabilities are being maximized. An error caused in part by lack of interoperability between two clinical information systems is discussed in a prior AHRQ WebM&M commentary.
Journal Article > Study
Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.
West P, Neily J, Warner L, et al. Jt Comm J Qual Patient Saf. 2014;40:235-239.
This study surveyed nurse managers to evaluate the implementation of pre-surgical briefings and post-surgical debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were variably sustained and team training appeared to augment implementation.
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.
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.