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- Review 2
- Study 7
- Slideset 1
- Book/Report 28
- Legislation/Regulation 1
- Newspaper/Magazine Article 77
- Toolkit 3
- Web Resource 20
- Communication Improvement 30
- Culture of Safety 9
- Education and Training 21
Error Reporting and Analysis
- Error Reporting 38
- Human Factors Engineering 14
- Legal and Policy Approaches 51
- Logistical Approaches 10
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 6
- Teamwork 3
- Clinical Information Systems 5
- Transparency and Accountability 5
- Device-related Complications 7
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 12
- Drug shortages 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 38
- Medication Safety 16
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 10
- Surgical Complications 20
- Transfusion Complications 3
- Surgery 5
- Nursing 3
- Pharmacy 2
- Family Members and Caregivers 14
- Health Care Executives and Administrators 39
Health Care Providers
- Nurses 3
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 14
- Canada 4
Search results for "Hospitals"
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
This radio news segment reports on patient falls, including risk factors and prevention strategies.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
Knox R. Morning Edition. National Public Radio. January 27, 2014.
Journal Article > Study
Etchegaray JM, Ottosen MJ, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.
Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.
Rosenberg T. New York Times. December 4, 2013.
Preventable adverse events may result in more harm than previously thought. Highlighting inconsistencies in publicly reported hospital safety data, this newspaper article explains how information is collected, analyzed, and presented by organizations such as Hospital Compare, Consumer Reports, and Leapfrog.
Department of Health. London, England: Crown Publishing; November 2013. ISBN: 9780101875424.
This report outlines actions that health care leaders in the United Kingdom have committed to take in order to address system problems identified by an inquiry into Mid Staffordshire National Health Services Foundation Trust.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
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.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Landro L. Wall Street Journal. September 30, 2013.
Allen M. ProPublica. September 19, 2013.
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
This magazine article reports on the unique tension between efficiency mandates and patient-centered care through the example of a cancer patient whose suicidal thoughts might have been missed if not for a curious medical student delving further into the patient's medication concerns during a routine follow-up appointment.
Rosenbaum L. The New Yorker: Elements. August 20, 2013.
This magazine article relates the risks and benefits associated with the 2003 resident work hour limits.
Tools/Toolkit > Measurement Tool/Indicator
This Web site provides resources to help employers and purchasers estimate latent costs related to unsafe care.
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.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.
Audiovisual > Audiovisual Presentation
Allen M, Pierce O, PBS Frontline, Ocupop. ProPublica. May 17, 2013.
This interactive presentation includes insights and stories about six common assumptions regarding hospital care that patients should know to improve their safety.