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Search results for "Audit and Feedback"
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.
Washington, DC: United States Government Accountability Office; October 28, 2011. Publication GAO-12-6R.
This report reviews injury claim data to assess quality of care in the Veterans Affairs health system.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.
This publication reports recommendations from a focus group exploring the utility of health information technology in enhancing quality measurement and discusses how the data can be used to improve care.
Journal Article > Study
Mull HJ, Nebeker JR, Shimada SL, Kaafarani HM, Rivard PE, Rosen AK. J Patient Saf. 2011;7:66-71.
Journal Article > Study
Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.
Addressing handoffs in patient care is a continued challenge, particularly around medication safety. Medication reconciliation was seen as a preventive strategy to handle such concerns, though the lack of proven strategies led The Joint Commission to soften its previous National Patient Safety Goal. A commonly held belief is that electronic health records (EHRs) provide solutions to communicating health information. This study compared medication reconciliation events for patient handoffs within a computerized VA system to a paper-based system outside the VA. Interestingly, there was no significant difference between medication discrepancies and adverse drug events (ADEs) in the highly computerized system. The authors suggest that their findings support a need for specialized tools to facilitate medication review at times of transfer. A past AHRQ WebM&M commentary discussed medication reconciliation after an avoidable error.
Journal Article > Review
Carpenter KB, Duevel MA, Lee PW, et al; Methods & Measures Working Group of the WHO World Alliance for Patient Safety. Qual Saf Health Care. 2010;19:48-54.
Providing background on the World Alliance for Patient Safety, this article reviews literature on patient safety methods in developing countries.
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).
Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The Rand Corporation; 2007. ISBN: 9780833041487.
This report is the second installment of a series commissioned to evaluate the success of the Agency for Healthcare Research and Quality's patient safety agenda and related programs.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.