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Search results for "Hospitals"
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.
This report highlights how working conditions can affect health care workers and recommends seven strategies for organizations to improve workplace safety.
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.
Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
This guide contains comprehensive information about best practices and implementation tools to help health care facilities build a culture of patient-centered care.
MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006).
Rockville, MD: United States Pharmacopeia; 2008.
This report provides an analysis of MEDMARX data from 870 hospitals on medication errors related to look-alike sound-alike drug names.
Golden, CO: Health Grades, Inc.; April 2006.
This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
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.
CHPSO: Sacramento, CA; 2019.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2018 trends, activities, and outcomes of initiatives at a 10-state PSO. Sections of the report include high-level review of reported medication and perinatal events, safe table data analysis, and strategies to improve incident reporting.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
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.
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to uncertainty, bias, and overconfidence that hinder accurate image assessment. Discussing the scope and impact of human error in diagnostic radiology, this book explores the future of advanced information technologies in diagnostic radiology and provides recommendations to reduce the effect of human fallibility on imaging interpretation.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.