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- Communication Improvement 5
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 5
- Human Factors Engineering 5
- Legal and Policy Approaches 7
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care 5
- Teamwork 2
- Clinical Information Systems 6
- Alert fatigue 1
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Failure to rescue 1
- Medical Complications 9
- Medication Safety 9
- Psychological and Social Complications 3
- Surgical Complications 4
- Internal Medicine 12
- Palliative Care 1
- Pharmacy 3
Search results for "Patients"
Tampa, FL: Sepsis Alliance; 2010.
Revealing incidents in which diagnostic delay led to sepsis, this video provides information to help consumers recognize the condition.
Washington, DC: Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
Journal Article > Study
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.
McFarling UL. STAT. September 7, 2016.
Intensive care units (ICUs) are complex environments that harbor various challenges to safe care delivery. Reporting on alarm fatigue and insufficient interoperability between devices in ICUs, this news article describes solutions to address data overload and highlights the efforts of several hospitals working toward developing ICUs that are more respectful of patients and the clinical teams caring for them.
Journal Article > Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014;165:1245-1251.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Journal Article > Study
Heyland DK, Barwich D, Pichora D, et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). JAMA Intern Med. 2013;173:778-787.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Agnvall E. AARP. November 16, 2012.
Journal Article > Study
Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.
Turner K, Frush K, Hueckel R, Relf MV, Thornlow D, Champagne MT. J Nurs Care Qual. 2013;28:257-264.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
Consumer Reports. January 26, 2012.
Consumer Reports analyzed publicly reported infection rates for 92 pediatric intensive care units (ICUs) and found that hospital-acquired infections were 20% higher in pediatric ICUs than in adult ICUs.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Luby R. KETV. Omaha, NE. March 31, 2010.
This news piece focuses on a heparin overdose that resulted in the death of a toddler.
Consumer Reports. March 2010;75:16-21.
Chen PW. New York Times. January 28, 2010.
This newspaper column explains how simulation training is being integrated into medical education to help clinical teams improve their skills and ensure patient safety.
Landro L. Wall Street Journal. September 1, 2009:D2.
This column explains that some hospitals now afford patients and families the right to summon an immediate clinical response to a patient's worsening condition.
Goldhill D. The Atlantic. September 2009.
In the context of his father's death from a hospital-associated infection, the author discusses health system reform and quality of care in the United States.
The Oprah Winfrey Show. March 10, 2009.
This feature spotlights Dennis Quaid's experience with medical errors and offers tips for patients on protecting their health.
Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.
Higgins W. Indianapolis Star. September 13, 2008;News section:A1
Families whose infants died from or were harmed by heparin overdoses are suing the drug manufacturer and the hospital.