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Search results for "Non-Health Care Professionals"
- Non-Health Care Professionals
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors call for Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. The deadline for submitting comments is June 30, 2019.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to uncertainty, bias, and overconfidence that hinder accurate image assessment. Discussing the scope and impact of human error in diagnostic radiology, this book explores the future of advanced information technologies in diagnostic radiology and provides recommendations to reduce the effect of human fallibility on imaging interpretation.
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.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.
Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019.
Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers.
Horsham, PA: Institute for Safe Medication Practices; January 2019.
Inaccurate or incomplete data in electronic health records can limit the effectiveness of health information technology. This guideline focuses on improvements in how medication information is formatted to support safe medication delivery. Recommended approaches include avoidance of error-prone abbreviations, use of Tall Man lettering, and required use of metric measurements to reduce risks in electronic health records, barcoding systems, smart infusion devices, and other information technologies.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Burnout can diminish the safety of clinicians, students, health care workers, and patients. This report suggests institutions apply design thinking and systems thinking methods to develop interventions to reduce burnout and stress. A past Annual Perspective covered the impact of burnout on patient safety.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
This guidance summarizes the current status of global patient safety, highlights World Health Organization efforts to address the problem, and provides direction for WHO leadership and policy makers to achieve improvements in safety. Recommendations include universal health coverage, coordination of efforts, and dissemination of effective practices.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Clinician burnout is a persistent threat to patient safety, and electronic health records have been identified as a high-profile contributor to the problem. This call for public comments on a draft report seeks insights on specific goals and recommended strategies to address the issue. The approaches outlined focus on reducing the time burden associated with frontline electronic health record use. The option for submitting comments is closed.