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Search results for "Hospital Medicine"
- Hospital Medicine
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.
Scoville R, Little K, Rakover J, Luther K, Mate K. Cambridge, MA: Institute for Healthcare Improvement; 2016.
Numerous activities and programs have been launched to improve patient safety, but sustaining improvements can be challenging. This white paper provides a framework that draws from key quality improvement concepts and Lean management tactics to help organizations integrate safety improvements in clinicians' daily work over time.
Fingar KR, Barrett ML, Elixhauser A, Stocks C, Steiner CA. HCUP Statistical Brief #195. Rockville, MD: Agency for Healthcare Research and Quality; November 2015.
Defining preventability has become increasingly important due to its use as a measure for cost and reimbursement mechanisms. This report presents data on hospitalizations for conditions that might be averted through quality ambulatory care and reveals that preventable hospital stays decreased between 2005 and 2012.
Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296.
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.
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
The Francis inquiry uncovered numerous problems in the National Health Service and led to many commentaries about improvement strategies. Summarizing achievements in applying recommendations following the inquiry, this report outlines where further work is needed to ensure that advances in safe care delivery are sustained. Companion materials available include an analysis exploring equality considerations and a table revealing the government response and progress for each of the 290 recommendations put forth in the original inquiry.
Safety Cases Working Group. London, UK: Health Foundation; 2015.
This report describes a consensus-building initiative in the United Kingdom seeking to determine ways safety cases can be used as learning tools. The results explain how to utilize cases to introduce changes, improve services, and enhance safety efforts in hospitals. Practical application of this technique may also help promote a culture of safety.
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.
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.
Oakbrook Terrace, IL: The Joint Commission; October 2013.
This Joint Commission report summarizes the performance of hospitals across 47 accountability measures—evidence-based metrics that are directly linked to patient outcomes. This year's calculation for identifying Top Performers included a new accountability measure for immunization. Top Performers are recognized by meeting three 95% performance thresholds; 1099 hospitals were identified. This represents 33% of all Joint Commission-accredited hospitals that report core measure performance data, a 77% increase compared to the previous year. Hospitals have measurably improved the quality of care over the past year for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.
Keogh B. London, UK: National Health Service; July 2013.
Outlining findings from an investigation into care delivered at National Health Service trusts with high mortality rates, this report details weaknesses in the organizations and recommends actions to address them.
Oakbrook Terrace, IL: The Joint Commission; September 2012.
The seventh annual Joint Commission report summarizes the performance of hospitals across 45 accountability measures—evidence-based metrics that are directly linked to patient outcomes. This year's calculation for identifying "Top Performers" included three new accountability measure sets: stroke, venous thromboembolism, and inpatient psychiatric services. "Top Performers" are recognized by meeting two 95% performance thresholds; 620 hospitals were identified. This represents 50% more hospitals than last year and now accounts for about 18% of all Joint Commission-accredited hospitals that report core measure performance data. According to the report, hospitals have measurably improved the quality of care over the past year for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Oakbrook Terrace, IL: Joint Commission; May 21–23, 2012.
Manchester, UK: General Medical Council; January 2012. ISBN: 9780901458568.
This guidance from the United Kingdom outlines how physicians can raise concerns and take appropriate action if they believe a patient's safety is at risk.
Oakbrook Terrace, IL: The Joint Commission; September 2011.
This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Portland, OR: Oregon Patient Safety Commission.
This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.
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.