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Search results for "Hospitals"
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013. Publication GAO-14-55.
Evaluation of provider behavior can identify problems that affect patient safety. This report analyzed data and expert interviews from four Veterans Affairs medical centers to identify weaknesses in peer review processes. Investigators found inconsistent adherence to peer review policy elements, such as timely review performance and peer review trigger development, and make recommendations to drive actions that address these issues.
Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.
Silence Kills was a 2005 report that highlighted communication failures that contribute to patient harm. These included broken rules, poor teamwork, and disruptive behaviors. This report builds on those findings based on a survey of more than 6500 nurses and nurse managers. Key findings suggested that existing safety tools, such as checklists, are not in themselves solutions to these communication failures. Nurses identified dangerous shortcuts, incompetence, and disrespect as three concerns that undermine systems designed to provide safer care. A past AHRQ WebM&M perspective and interview discuss the role of checklists in health care settings.