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- Communication Improvement 15
- Culture of Safety 11
- Education and Training 13
- Error Reporting and Analysis 4
- Human Factors Engineering 5
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 10
- Specialization of Care 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 3
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications 5
- Internal Medicine 11
- Surgery 4
- Nursing 1
- Health Care Executives and Administrators 25
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
- Patients 1
Search results for "Hospitals"
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.
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.
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.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance—A Handbook for Acute Care Health Professionals.
Brindley P, Cardinal P, eds. Ottawa, ON, Canada: Royal College of Physicians and Surgeons of Canada; 2017. ISBN: 9781926588414.
Nontechnical skill development has gained attention as a way to enhance patient safety. This publication highlights how crisis resource management can help develop nontechnical expertise to enhance team performance. Strategies covered in the text include situational awareness, team communication, decision making, and leadership in the acute care environment.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.
Chicago, IL: Health Research & Educational Trust; June 2015.
This guide draws from the experience of organizations that have used TeamSTEPPS to illustrate how the program has contributed to patient safety and quality improvement efforts. Lessons learned include the value of engaging leadership, utilizing debriefing as a learning mechanism, and the need to avoid a one-size-fits-all approach to training.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
Health care has been recently been directed toward focusing on the value of teamwork in reducing risks. This publication provides extensive information about team training, including key concepts, guidelines, insights from health care workers, and strategies to improve teamwork and monitor performance.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.
This publication provides various strategies to drive innovation in patient safety, including how to eliminate unsafe practices.
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
This report describes how teams participating in The Joint Commission's Center for Transforming Healthcare hand hygiene initiative utilized techniques to examine hand hygiene processes and identified the most common reasons why clinicians don't wash their hands.
Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN: 9780833050557.
This report studied teamwork development experiences of labor and delivery units to identify processes and dynamics that affected teamwork improvement.
Women's Health Care Physicians; Committee on Patient Safety and Quality Improvement. Washington, DC: American College of Obstetricians and Gynecologists; 2010. ISBN: 9781934946930.
This manual describes various facets of health care quality and tools for quality improvement in obstetric and gynecologic practice.
Cambridge, MA: Institute for Healthcare Improvement; February 2010.
This manual offers practical advice on how to plan for and implement care team rounds that involve a variety of health care providers.
Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.
This guide introduces strategies for hospital managers to prevent avoidable readmissions.
Cooper H, Findlay G, Goodwin APL, et al. London, UK: National Confidential Enquiry into Patient Outcome and Death; November 2009. ISBN: 9780956088222.
This United Kingdom report analyzed more than 2000 cases of in-hospital patient deaths and found weaknesses in care coordination, communication across teams, and senior-level clinician oversight.