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Search results for "Educators"

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Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Meeting/Conference > Ohio Meeting/Conference

TeamSTEPPS National Conference.

Agency for Healthcare Research and Quality. June 14–16, 2017; Hilton Cleveland Downtown, Cleveland, OH.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This annual conference will present techniques, tools, and innovations to help health care professionals implement and utilize the TeamSTEPPS model. 

Meeting/Conference > Maryland Meeting/Conference

Patient Safety Certificate Program.

Armstrong Institute for Patient Safety and Quality.June 12-16, 2017; Constellation Energy Building, Baltimore, MD.

This course will cover various patient safety topics, including key concepts and human factors engineering strategies. The program will also explore the comprehensive unit-based safety program model of safety improvement. Participants will be engaged in problem-solving and developing patient safety initiatives.

Journal Article > Commentary

You can't blame the wreck on the train.

Potts JR III. Am J Surg. 2016 Dec 21; [Epub ahead of print].

Insufficient supervision can limit resident education, which may increase risks to patient safety. This commentary outlines factors that reduce the effectiveness of general surgery resident supervision and provides suggestions to augment supervision, including developing policies that outline when resident supervision is required and educating hospital executives about the need for appropriate oversight of care delivered by trainees.

Book/Report

Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.

McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.

Journal Article > Commentary

Ethical considerations in the development of the Flexibility in Duty Hour Requirements for Surgical Trainees trial.

Minami CA, Odell DD, Bilimoria KY. JAMA Surg. 2017;152:7-8.

Patient safety research has generated some concern regarding ethical implications involved in implementing changes that affect patient care. This commentary discusses ethical challenges related to a large trial that explored the effects of duty hour flexibility. The authors discuss policy changes, institutional review board roles, and informed consent as tactics to address concerns.

Book/Report

Healthcare Simulation Dictionary.

Lopreiato JO, Downing D, Gammon W, et al; Terminology & Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16(17)-0043.

Developed by AHRQ in partnership with the Society for Simulation in Healthcare, this dictionary represents an effort to standardize language associated with simulation in order to improve communication about and application of the strategy. The terms in the initial collection will be expanded and revised over time.

Grant > Government Resource

Advances in Patient Safety through Simulation Research (R18).

Rockville, MD: Agency for Healthcare Research and Quality. PA-16-420.

This grant will support funding for the development, testing, and evaluation of simulation as a mechanism to identify opportunities for improvements in safety. The submission process opens November 25, 2016 and is scheduled to run until January 26, 2022.

Tools/Toolkit > Government Resource

TeamSTEPPS for Office-Based Care Version.

Rockville, MD: Agency for Healthcare Research and Quality; April 2016.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.

Meeting/Conference > Government Resource

TeamSTEPPS Master Training Course.

Agency for Healthcare Research and Quality, Health Research & Educational Trust. March-September 2017.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This series of trainings will prepare participants to guide their organizations through implementation of the TeamSTEPPS program.

Journal Article > Study

Developing an appreciation of patient safety: analysis of interprofessional student experiences with health mentors.

Langlois S. Perspect Med Educ. 2016;5:88-94.

Health profession educators are prioritizing integration of patient safety and quality improvement concepts into their curricula. In this study, interprofessional groups of students were paired with a health mentor—a patient with a chronic illness—and through interviews and reflection students identified various safety issues that affected their mentor's health. These included the importance of care coordination and patient-centered care.

Tools/Toolkit > Multi-use Website

TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.

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Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016.

Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.

Journal Article > Review

Simulation-based training: the missing link to lastingly improved patient safety and health?

Mileder LP, Schmölzer GM. Postgrad Med J. 2016;92:309-311

Simulation has been increasingly accepted as a training strategy for both technical and teamwork skills. This review summarizes the evidence on use of simulation to develop skills both for individuals and teams across various health care professions and how to sustain improvements.

Journal Article > Commentary

An organizational learning framework for patient safety.

Edwards MT. Am J Med Qual. 2017;32:148-155.

Organizations are encouraged to learn from their failures, but evidence shows that changes after errors are not always implemented. This commentary presents a model to help organizations learn from system failures through focusing on improvements that align collaboration, accountability, culture, and process enhancement with elements of high reliability.

Journal Article > Study

The impact of the 2011 Accreditation Council for Graduate Medical Education duty hour reform on quality and safety in trauma care.

Marwaha JS, Drolet BC, Maddox SS, Adams CA Jr. J Am Coll Surg. 2016;222:984-991.

Current studies suggest that the ACGME duty hours reform in 2011 did not substantially affect patient outcomes. Consistent with prior work, this retrospective cohort study found no differences in primary outcomes such as mortality. However, the authors suggest that future studies examine other quality metrics that may have changed after the duty-hours reform.

Journal Article > Commentary

The promise of big data: improving patient safety and nursing practice.

Linnen D. Nursing. May 2016;46:28-34.

Big data is gaining attention as a way to improve quality and safety. This commentary discusses how outcomes data can be applied to enhance safety of nursing care and reviews limitations to successfully using analytics, including insufficient interoperability and inadequate funding to design effective tools.

Journal Article > Study

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. J Pediatr Nurs. 2016;31:e283-e290.

This Canadian study found that nurses with more experience reported a greater number of pediatric medication administration errors, but these errors were less severe compared to other units. This finding suggests widespread underreporting of medication errors by nurses with a lower level of experience.

Journal Article > Study

National cluster-randomized trial of duty-hour flexibility in surgical training.

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Bilimoria KY, Chung JW, Hedges LV, et al. N Engl J Med. 2016;374:713-727.

Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.

Journal Article > Study

Associations between attending physician workload, teaching effectiveness, and patient safety.

Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. J Hosp Med. 2016;11:169-173.

The volume–outcome relationship—in which increased patient volume is associated with improved outcomes at the individual clinician and hospital level—has been demonstrated in several classic studies of surgical outcomes. However, this analysis of medical admissions to a teaching hospital found indications of an opposite association. Analyzing admissions over a 6-year period, investigators found that a higher total patient census and a greater number of daily admissions were both associated with an increased frequency of safety events (as measured by the AHRQ Patient Safety Indicators). Greater total census and more admissions were both inversely associated with teaching evaluation scores. Taken together, these results imply that increased workload impairs faculty physicians' ability to supervise and teach residents effectively.

Journal Article > Commentary

Fake and expired medications in simulation-based education: an underappreciated risk to patient safety.

Torrie J, Cumin D, Sheridan J, Merry AF. BMJ Qual Saf. 2016;25:917-920.

Simulation-based education in health care is common, and typically training exercises use artificial and expired medications instead of actual products. This commentary describes how these fake medications can introduce risks when they are accidentally incorporated into active medication inventory and suggests strategies to reduce such confusion in care environments.

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