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Search results for "Education and Training"

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Press Release/Announcement

FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.

Silver Spring, MD: US Food and Drug Administration; April 9, 2019.

Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.

Book/Report

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2018.

This report summarizes progress in patient safety improvement in the past decade and reviews the 2017 activities of the Patient Safety Authority, including an update on efforts to standardize their reporting processes and to reduce health care–associated infections in nursing homes. The report also summarizes the new 5-year strategic plan for the agency that explicitly emphasizes a focus on improving diagnosis.

Journal Article > Review

Patient safety in geriatrics: a call for action.

Tsilimingras D, Rosen AK, Berlowitz DR. J Gerontol A Biol Sci Med Sci. 2003;58:M813-M819.

This review discusses medication errors and patient safety in the context of geriatrics and offers recommendations to improve safety for elderly patients.

Newspaper/Magazine Article

IV push medications survey results—part 1 and part 2.

ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.

Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.

Journal Article > Study

A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions.

Mathew R, Gundy S, Ulic D, Haider S, Wasi P. Acad Med. 2016;91:1284-1292.

Although duty hour restrictions were enacted to improve patient safety, evidence regarding their impact has been mixed. This focus group study examined resident perceptions of quality of life and patient safety before and after implementation of a reduced duty hours model. Participants reported less fatigue but also expressed concern about the greater number of handoffs, echoing the ongoing duty-hours debate discussed in a recent PSNet perspective.

Book/Report

Patient and Family Engagement in Primary Care: Case Studies.

Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Journal Article > Commentary

Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach.

Parker KM, Harrington A, Smith CM, Sellers KF, Millenbach L. J Nurses Prof Dev. 2016;32:56-63.

Disruptive behavior is common in health care settings. This commentary discusses the development and implementation of a multifaceted initiative to address unprofessional conduct among nurses. The authors highlight the importance of involving the organization, leaders, and individuals in achieving culture change.

Web Resource > Multi-use Website

National Coalition for Alarm Management Safety.

Healthcare Technology Safety Institute and Association for the Advancement of Medical Instrumentation.

Alarm fatigue has been recognized as a contributor to serious errors in hospitals. This Web site provides a way for hospitals, industry representatives, regulators, and professional societies to compile resources and discuss strategies to reduce unnecessary alarms.

Audiovisual > Audiovisual Presentation

SAFER Guides: What You Need to Know.

American Hospital Association. December 3, 2014. 

Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.

Journal Article > Commentary

Prevention of fatal opioid overdose.

Beletsky L, Rich JD, Walley AY. JAMA. 2012;308:1863-1864.

This commentary recommends that health care providers and government agencies contribute to efforts to prevent opioid overdoses through strategies such as raising awareness, publicizing overdose education, and screening patients for overdose risk.

Audiovisual

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.

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 > Study

Exploring the causes of adverse events in hospitals and potential prevention strategies.

Smits M, Zegers M, Groenewegen PP, et al. Qual Saf Health Care. 2010;19:e5.

This study analyzed more than 700 adverse events in order to identify latent causes of errors.

Special or Theme Issue

Obstetric Issues.

PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.

Articles in this supplement draw from labor, delivery, and obstetric safety reports to provide insights for safe practice in obstetrics.

Journal Article > Study

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

This study discovers that using selected failure to rescue process measures may help identify areas for improvement in perinatal care.

Cases & Commentaries

Recurrent Hypoglycemia: A Care Transition Failure?

  • Spotlight Case
  • Web M&M

Ted Eytan, MD, MS, MPH; October 2008

An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.

Audiovisual

Vincristine: Learning from Error Workshop.

World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.

Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.

Journal Article > Commentary

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.

Cases & Commentaries

Do Not Disturb!

  • Spotlight Case
  • Web M&M

F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007

Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.

Perspectives on Safety > Perspective

Making Just Culture a Reality: One Organization's Approach

with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007

We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.

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