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Communication between Providers
- Sbar 1
- Communication between Providers 19
- Culture of Safety 3
Education and Training
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- Human Factors Engineering 4
- Legal and Policy Approaches 16
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- Quality Improvement Strategies 13
- Specialization of Care 3
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- Device-related Complications 4
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- Discontinuities, Gaps, and Hand-Off Problems
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- Identification Errors 4
- Medical Complications 6
- Medication Safety 15
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 5
- Ambulatory Care 9
- General Hospitals 14
- Long-Term Care 1
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- Internal Medicine 18
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- Pharmacy 3
- Family Members and Caregivers 6
- Health Care Executives and Administrators 23
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
Search results for "Patients"
Journal Article > Study
The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.
Tothy AS, Limper HM, Driscoll J, Bittick N, Howell MD. Jt Comm J Qual Patient Saf. 2016;42:281-286.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Journal Article > Commentary
Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.
This commentary discusses a federal proposal to provide patients with direct access to laboratory test results as a tactic to reduce errors.
Journal Article > Commentary
Griffin T. J Perinat Neonatal Nurs. 2010;24:348-353.
This commentary describes nurse change-of-shift reports as a tactic to improve communication with patients and families to promote safe care.
Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
This trio of public service announcements promotes safe medication use, informed discharge, and family and friends as advocates in the hospital.
Tools/Toolkit > Glossary
Chicago, IL: Consumers Advancing Patient Safety; 2009.
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Tools/Toolkit > Government Resource
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
Parker L. USA Today. December 19, 2006.
This article reports on the case of an elderly patient whose advance directive wasn't followed and discusses the impact of this omission.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
Kowalczyk L. Boston Globe. July 29, 2017.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Landro L. Wall Street Journal. October. 26, 2015.
Journal Article > Study
The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-507.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
Bond A. New York Times. June 16, 2015.
Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
LaFraniere S. New York Times. April 19, 2015.
Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
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.