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Search results for "Audit and Feedback"
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.
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.