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Search results for "Education and Training"

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Special or Theme Issue

Quality, Value, and Patient Safety in Orthopedic Surgery.

Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.

Journal Article > Study

Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

  • Classic

Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2016 Jan 7; [Epub ahead of print].

A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.

Tools/Toolkit > Government Resource

Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit.

Itasca, IL: American Academy of Pediatrics; 2018.

Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.

Journal Article > Study

A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.

Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018;13:324-330.

Medication administration errors are common and costly, especially for children. Investigators conducted a multipronged quality improvement intervention for pediatric medication administration. First, they implemented a one-time simulation training for pediatric bedside nurses across emergency department, hospital ward, and intensive care settings to foster use of standardized medication administration best practices. They observed bedside nursing via audits for 18 months of follow-up. Adherence to best practices improved from 51% of medication administration instances to 84%, and the rate of medication administration errors declined significantly. The authors suggest that simulation training is an effective strategy to improve the safety of pediatric medication administration.

Journal Article > Study

Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences.

Destino LA, Kahana M, Patel SJ. Jt Comm J Qual Patient Saf. 2016;42:99-110.

Morbidity and mortality conferences are a time-tested educational strategy for patient safety. This study demonstrates that using a structured tool to facilitate systems-based learning resulted in increased resident engagement in quality improvement practices. The results demonstrate the benefits of widespread implementation of system-based morbidity and mortality conferences.

Audiovisual > Audiovisual Presentation

Profiles in Excellence: Quality Improvement Lessons--Parts 1 and 2.

American Hospital Association and Health Research and Educational Trust. November-December 2015.

The AHA-McKesson Quest for Quality Prize winners are recognized for commitment to the goals outlined in Crossing the Quality Chasm. These webinars shared insights from health care organizations that received recognition in 2015 for implementing programs to form partnerships with patients, families, and their communities to generate improvements in health care and eliminate harm.

Journal Article > Study

Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy.

Shah R, Blustein L, Kuffner E, Davis L. J Pediatr. 2014;164:596-601.

This observational study of community pharmacies found that liquid medication dosing instructions for pediatric patients did not consistently reflect recommended best practices. This finding underscores the need to translate safety research into clinical practice.

Perspectives on Safety > Perspective

Safety in Radiology

with commentary by Antonio Pinto, MD, PhD, Safety in Radiology, October 2013

This piece explores how to mitigate risks associated with radiology procedures.

Journal Article > Study

Factors associated with medication errors in the pediatric emergency department.

Vilà-de-Muga M, Colom-Ferrer L, Gonzàlez-Herrero M, Luaces-Cubells C. Pediatr Emerg Care. 2011;27:290-294.

Prescribing errors in a pediatric emergency department were more frequent on weekends and at night, and residents committed errors more frequently than attending physicians.

Journal Article > Study

Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents.

Bertsche T, Bertsche A, Krieg EM, et al. Qual Saf Health Care. 2010;19:e26.

A quality improvement program successfully reduced the incidence of medication administration errors in pediatric inpatients.

Journal Article > Study

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

Patient misidentification errors are surprisingly common, as demonstrated in studies in the inpatient and emergency department settings. In this study, a children's hospital conducted a continuous quality improvement intervention to reduce misidentification errors. Interventions—many of which were suggested by staff—included wristband standardization and a "stop-the-line" policy if a misidentification error was suspected. The project resulted in a significant and sustained reduction in these errors. An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the labeling of phlebotomy specimens.

Journal Article > Commentary

Health literacy and quality: focus on chronic illness care and patient safety.

Rothman RL, Yin HS, Mulvaney S, Co JPT, Homer C, Lannon C. Pediatrics. 2009;124(suppl 3):S315-S326.

This article describes how health literacy affects care for pediatric patients with chronic illnesses as well as efforts to promote safe care in this population.

Journal Article > Study

Improving patient safety: effects of a safety program on performance and culture in a department of radiology.

Donnelly LF, Dickerson JM, Goodfriend MA, Muething SE. AJR Am J Roentgenol. 2009;193:165-171.

This study found that implementation of a comprehensive and multifaceted safety program improved reports of safety culture among pediatric radiologists.

Book/Report

Review of Patient Safety for Children and Young People.

London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.

Analyzing research and more than 900,000 incident reports submitted to the National Patient Safety Agency, this report identifies adverse events affecting children and emphasizes actions for stakeholders to enhance safety for pediatric patients in the United Kingdom.

Journal Article > Study

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.  

Medication errors are a common problem in pediatric outpatients, and high-alert medications such as opioid analgesics are a major cause of emergency department visits in both children and adults. This study evaluated the quality of analgesic prescriptions in patients being discharged from a pediatric teaching hospital. Most prescriptions contained at least one error, including frequent use of error-prone abbreviations and failure to use weight-based dosing, and 3% of prescriptions were judged to have the potential for serious patient harm. Computerized provider order entry (CPOE) has been advocated as a means of preventing medication errors in children, but in a prior study, CPOE actually failed to reduce dosing errors in children.

Audiovisual > Audiovisual Presentation

Preventing Medical Errors.

Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.

This collection of video segments offers information on common types of medical errors, particularly medication errors, based on reports to the Institute for Safe Medication Practices.

Newspaper/Magazine Article

National safety effort targets perinatal injuries.

O'Reilly KB. American Medical News. June 16, 2008;15:17. 

This article reports on an initiative to prevent birth injuries through improved communication techniques and evidence-based care interventions.

Journal Article > Study

Decreasing paediatric prescribing errors in a district general hospital.

Davey AL, Britland A, Naylor RJ. Qual Saf Health Care. 2008;17:146-149.

A prescribing tutorial for junior doctors successfully reduced medication prescribing errors in a children's hospital.

Journal Article > Study

Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.

Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Pediatrics. 2006;118:e1124-e1129.

This study describes an effort to reduce adverse drug events (ADEs) at a pediatric tertiary care hospital through interventions targeting the clinical staff. These interventions included use of a Web-based tutorial on medication safety, a "zero-tolerance" policy whereby any medication errors would have to be rewritten, and feedback of individual data on prescribing error to clinicians. The intervention achieved impressive reductions in potential ADEs, defined as any incompletely written medication order, but did not document the incidence of ADEs resulting in patient harm. The baseline incidence of potential ADEs was also higher than that seen in prior research.

Cases & Commentaries

Confusion With Acetaminophen

  • Web M&M

James E. Heubi, MD ; January 2006

Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage.

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