Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 4
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 13
- Human Factors Engineering 3
- Legal and Policy Approaches 6
- Policies and Operations 2
- Quality Improvement Strategies 5
- Research Directions 1
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 2
- Medication Safety 3
- Psychological and Social Complications
- Surgical Complications 3
- Family Members and Caregivers 2
- Health Care Executives and Administrators 31
- Health Care Providers 26
- Non-Health Care Professionals 23
- Patients 9
Search results for "Psychological and Social Complications"
- Psychological and Social Complications
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.
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.
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.
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.
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
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.
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
Clinician burnout presents challenges to organizational and patient safety. This publication summarizes survey responses from clinical leadership, health care executives, and clinicians regarding the extent of the problem and solutions to reduce its prevalence in health care. Respondents considered organizations to be accountable for improvement and they reported self-care as important to manage the impact of burnout.
Dusenbery M. New York, NY: HarperOne; 2018. ISBN: 9780062470805.
Implicit biases can affect diagnostic decision-making. This book discusses biases and cultural limitations that influence the safety of women's health care. Systemic problems are highlighted, such as lack of respect for patient concerns and insufficient biomedical research examining treatments and their effect on women.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.
Clinician burnout has recently emerged as a patient safety concern. This report from a national initiative to examine burnout provides initial insights from its work and targets areas requiring further study, such as a focus on system factors that facilitate the problem, the effect of clinician wellbeing on outcomes, and interventions to improve the clinicians' work lives.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
This report provides the insights from a panel exploring the need for transparency after a medical mistake occurs. The session discussed the history and evolution of new approaches to achieve transparency, such as communication-and-resolution programs. Experts participating in the session included Dr. David Mayer, Richard Boothman, and Helen Haskell.
Hatch S. New York, NY: Basic Books; 2016. ISBN: 9780465050642.
Francis R. London, UK: Freedom to Speak Up Review; February 2015.
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.
Manchester, UK: General Medical Council; November 2014.
Carr S. Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009.
This report describes results of a multidisciplinary effort to develop programs to help clinicians cope with errors that result in patient harm.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
This workbook includes background on disruptive behaviors and provides tools for health care managers to develop awareness initiatives and policies to reduce the impact and occurrence of such behavior.
Weick KE. Thousand Oaks, CA: Sage Publications; 1995.
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen in his story Escape Fire, which illustrates the disasters that befall teams when "sensemaking" is absent or disappears in a crisis. Weick's thinking encompasses the notion that both individuals and teams often overlook important problems because they put on cognitive blinders based on their biases and expectations and that individuals or teams working in complex enterprises often err because they lose the ability to make rational decisions in the face of crises. All of this is useful and intuitively logical, although one finishes Weick's book not entirely sure how to improve sensemaking in a clinical context.
Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. San Francisco, CA: Jossey-Bass; 1993. ISBN 9781555425449.
Authored by several leaders of the Picker/Commonwealth Program for Patient-Centered Care, this book demonstrates the broad impact of the program. The authors discuss the key tenets of patient-centered care, drawing on empirical research, theory, and results of many surveys of patients, providers, and administrators. The authors provide many practical suggestions, a number of which have been adopted since the book's first publication in 1993. Examples include giving patients access to their medical records, giving them ''written and/or visual information identifying members of the clinical team," and offering ''culturally sensitive educational materials tailored to specific ethnic groups.''
Paget MA. Philadelphia, PA: Temple University Press; 1988. ISBN: 0877225338.
In this often described landmark text on the nature of medical error, Marianne Paget uses a detailed series of physician interviews to illustrate the complexities of mistakes in medicine. She carefully describes the language associated with concepts such as mistake, fault, negligence, and blame. She provides a thoughtful and provocative analysis of these clinical events and probes how physicians think about their mistakes, including the associated psychological burden in confronting them. The large number of actual transcripts shared throughout her text creates opportunities to get inside the head of well-intentioned physicians who struggle with avoiding mistakes.
Patient Safety Ethics: How Vigilance, Mindfulness, Compliance, and Humility can Make Healthcare Safer.
Banja JD. Baltimore, MD: Johns Hopkins University Press; 2019. ISBN: 9781421429083.
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.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Denver, CO: Healthgrades Operating Company, Inc; 2015.
Analyzing data from the Hospital Consumer Assessment of Healthcare Providers and Systems, this report discusses hospital efforts to understand measures of patient experience and reveals how 32 institutions recognized for their patient safety status were found to have had improved outcomes over time as demonstrated through the application of patient safety indicators. The publication includes a list of hospitals that received the 2015 Healthgrades Patient Safety Excellence Award.
Chicago, IL: Health Research & Educational Trust; 2015.
Patient and family advisor programs have been implemented in health care as a way to incorporate the experiences of consumers into safety improvement work. This guide provides a framework to help hospitals develop partnership initiatives that focus on advisor recruitment, education, and teamwork to enhance efforts to engage patients and families in this role.
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.
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
When medical errors occur, patients desire full disclosure. This report calls for clinicians in the National Health Service to disclose errors that contribute to moderate or severe harm or death. The authors outline recommendations to help organizations establish a safety culture that requires discussion about unanticipated events and ensures that staff receive training in apologies.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
London, UK: Health Policy & Economic Research Unit, British Medical Association Scotland; May 2010.
This report summarizes findings from a survey querying physicians about United Kingdom National Health Service whistleblowing policies.
Chabris C, Simons D. New York, NY: Crown Publishing Group; 2010. ISBN: 0307459659.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Oakbrook Terrace, IL: Joint Commission Resources; 2008. ISBN: 9781599402291.
This handbook describes characteristics of the health care work environment that contribute to fatigue and burnout and introduces strategies to address them.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Berlinger N. Baltimore, MD: Johns Hopkins University Press; 2005. ISBN: 0801881676.
The author draws from theological, ethical, religious, and cultural foundations to understand the actions that should be taken after a medical mistake.
Sharpe VA. Hasting Center Rep. 2003;33(suppl):S1-S20.
The results of a two-year Hastings Center project to elucidate ethical concerns that affect the dialogue in developing effective patient safety policies.
Bosk CL. Chicago, IL: University of Chicago Press; 2003. ISBN: 0226066789.
In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing the surgical residents and faculty at an unnamed hospital, in the process exploring the balance between autonomy and oversight in medical training, how physicians deal with their errors, and the nature of accountability in the medical profession. This edition, published more than two decades after Forgive and Remember was first published, includes a new prologue, epilogue, and list of appendices. The book is informative for both lay readers and clinicians.