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Search results for "General Hospitals"
Award > Award Announcement
APSF Committee on Technology. Anesthesia Patient Safety Foundation.
Medication errors in anesthesia practice can be result in serious patient harm. This award will recognize organizations that have focused on improving anesthesiology medication delivery through process standardization, information technology use, medication management, and safety culture. The award submission process is now closed.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Journal Article > Study
Naessens J, Campbell CR, Shah N, et al. Am J Med Qual. 2012;27:48-57.
The epidemiology of adverse events on a population basis has been well studied, but how these data translate to risks for individual patients is not as clear. The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this study sought to evaluate a complementary question: whether patients who are more severely ill at admission are at increased risk of preventable harm. By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error reports, and infection control reports—to clinical databases, the authors were able to show that higher illness severity is associated with an increased risk of adverse events during hospitalization. These findings are supported by the fact that intensive care unit patients have consistently been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient with multiple underlying comorbidities.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.