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- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
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- Quality Improvement Strategies 2
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- Technologic Approaches 1
Search results for "Medicine"
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
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.
Web Resource > Multi-use Website
Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Journal Article > Commentary
Lacker C. Am J Nurs. 2011;111:65-69.
Analyzing data from the Pennsylvania Patient Safety Authority Reporting System, this commentary identifies contributing factors to readmissions and suggests tactics to prevent them.
PA-PSRS Patient Saf Advis. 2010;7:123-134.
This report examines how optimizing patient flow from emergency department arrival to diagnosis can enhance quality and safety.
Journal Article > Commentary
Huber C, Blanco M. Am J Nurs. 2010;110:66-69.
This article discusses problems associated with discharge and highlights the importance of beginning the planning process at admission and engaging the team to ensure successful discharge.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.