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Search results for "Hospitals"
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.
Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
This guide contains comprehensive information about best practices and implementation tools to help health care facilities build a culture of patient-centered care.
Golden, CO: Health Grades, Inc.; April 2006.
This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
The role of hospital boards in influencing and financing efforts to improve safety is of recognized importance. However, leaders must have the skills and mindset needed to understand and perform quality governance responsibilities. This report provides a framework drawn from the Institute of Medicine six elements of quality to clarify responsibilities of trustees and health system leaders with regard to quality oversight.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
In: 2018 Comprehensive Accreditation Manual for Hospitals. CAMH. Oakbrook Terrace, IL: Joint Commission; January 2018:PS1-PS50.
This chapter provides information about how organizations can re-design existing programs or launch new initiatives working to meet National Patient Safety Goal and accreditation standards. The material focuses on the importance of integrating safety and quality work with frontline activities, evaluating progress of interventions, and learning from critical events to guide improvements.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
Oakbrook Terrace; IL: Joint Commission; 2017.
The Joint Commission annual report provides performance data for United States hospitals across a range of accountability measures and highlights changes associated with quality measurement. In 2016, hospital performance on accountability measures remained strong. Although the composite accountability score decreased slightly, this result is thought to be due to the fact that measures were retired that had high performance in the past. In 2016, 59.6% of hospitals achieved overall composite performance of greater than 95%. The report also describes the Pioneers in Quality program, which was designed to facilitate hospital reporting of electronic clinical quality measures. In 2016, 470 hospitals reported electronic clinical quality measure data compared to only 34 in 2015. In a PSNet interview, the president and chief executive officer of The Joint Commission discusses high reliability in health care.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process.
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017.
Advocates for improving diagnosis emphasize the role of the patient as key to success. This report examines factors to consider when designing interventions to strengthen patient participation in the diagnostic process. Recommendations to enhance relationships with patients to reduce diagnostic error focus on managing misperceptions that can affect decision-making and communication.
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Boston, MA: National Patient Safety Foundation; March 2017.
A public health approach to patient safety could help drive improvement efforts. This report recommends that health care draw from successes targeting health care–associated infections to design medical error reduction programs from this perspective. The authors provide a structured method for leaders and policymakers to generate lasting change in patient safety.
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Oakbrook Terrace, IL: The Joint Commission; November 2016.
This Joint Commission annual report describes performance data for United States hospitals across a large number of evidence-based measures, referred to as accountability measures. The report highlights 2015 as a year in which The Joint Commission implemented many changes. Given excellent performance by hospitals in previous years and to align more closely with the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program, The Joint Commission decreased the number of accountability measures from 49 to 29. The percent of hospitals that performed at 95% or above for all accountability measures declined from 80.3% in 2014 to 61% in 2015. However, the report emphasizes that many of the measures in which hospitals were performing extremely well were among those that were removed, and hospitals continued to improve on individual accountability measures. In addition, The Joint Commission introduced flexible reporting options giving hospitals some choice in which metrics to report. Hospitals were also given the opportunity to submit electronic clinical quality measure data for the first time. A previous WebM&M commentary discussed the unintended consequences of public reporting of hospital quality.
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
Engaging hospital leadership in patient safety is imperative to gaining funding for and sustaining the results of improvement work. This publication introduces board members to key concepts in patient safety and quality improvement. The book covers topics such as high reliability and transparency and uses case studies to illustrate the value of interventions.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.