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Search results for "Education and Training"
Journal Article > Study
Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.
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.
Journal Article > Study
O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.
Interdisciplinary teamwork is a primary driver of safety culture, and lack of teamwork has been linked to poor clinical outcomes in surgery and the emergency department. Creating high-functioning teams is challenging in inpatient medicine wards, due to numerous barriers including variability in physician and nurse schedules and communication styles. This study, which built on prior work by the same authors, sought to improve interdisciplinary teamwork at a teaching hospital by creating structured, daily rounds where the entire care team discussed patients. The intervention resulted in a significant decrease in preventable adverse events compared with historical and concurrent controls. The accompanying editorial notes that the hospital where this study was conducted had several structural features that also encouraged interdisciplinary communication (such as an electronic health record), and that structured interdisciplinary rounds could have an even larger impact at hospitals lacking such features.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
Journal Article > Study
de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. N Engl J Med. 2010;363:1928-1937.
A landmark study in patient safety demonstrated remarkable improvement in surgical outcomes through implementation of a checklist for intraoperative and perioperative care. However, inconsistencies in postoperative care are thought to contribute to persistent variation in surgical outcomes between hospitals. In this controlled study, a comprehensive system for the entire surgical pathway—from admission to discharge—was implemented at six teaching hospitals in the Netherlands, and resulted in significant reductions in both complications and overall mortality. The authors note that the success of their intervention relied as much on developing a culture of safety as on the checklist itself, a point supported by another recent study that achieved significant improvement in surgical outcomes through teamwork training.
Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.
Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient safety movement and continues to publish groundbreaking research in the field. This essential textbook discusses the evolution of patient safety efforts, outlines current medical error reduction strategies, and emphasizes practical examples of initiatives to improve patient safety. Dr. Vincent was interviewed for AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the United Kingdom.
Journal Article > Commentary
Leape L, Berwick D, Clancy C, et al; Lucian Leape Institute at the National Patient Safety Foundation. Qual Saf Health Care. 2009;18:424-428.
Although significant progress has been made in improving patient safety over the past decade, most health care organizations still experience persistent safety problems. In this commentary, leaders of several leading safety organizations endorse five principles for transforming hospitals and clinics into high reliability organizations. These include transparency in disclosing errors and quality problems, integration of care across teams and disciplines, engaging patients in safety, developing a culture of safety, and reforming medical education to focus on quality and safety. The lead author, Dr. Lucian Leape, was interviewed about his remarkable career in patient safety by AHRQ WebM&M in 2006.
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.
The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.
Journal Article > Commentary
Buerhaus PI. Health Affairs. 2007;26:w687-w696.
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. This engaging interview with Dr. Leape shares his thoughts on the current state of patient safety and how the health care system is responding. He reflects on the success of the 100,000 Lives Campaign, Michigan's efforts to eliminate central line infections, the development of trigger tools to identify adverse events, and increased attention to error disclosure. On the other hand, he also discusses the need for greater teamwork training, more effective hospital leadership, and improved quality and safety curricula. An AHRQ WebM&M conversation with Dr. Leape also discusses his remarkable career and his thoughts on the patient safety movement.