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Meeting/Conference > Maryland Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 17-18, 2018; Constellation Energy Building, Baltimore, MD.

This 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 > Maryland Meeting/Conference

Patient Safety Certificate Program.

Armstrong Institute for Patient Safety and Quality. August 13-17, 2018; 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.

Meeting/Conference > United States Meeting/Conference

TeamSTEPPS Master Training Course.

AHA Team Training. July 9–November 9, 2018; various locations.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This session will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. Nine 2-day sessions will be held over the course of 2018.

Tools/Toolkit > Government Resource

CUSP Toolkit.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; January 2018.

The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts.  Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.

Tools/Toolkit > Government Resource

TeamSTEPPS 2.0 for Long-Term Care.

Rockville, MD: Agency for Healthcare Research and Quality; November 2017.

This toolkit provides resources to help implement TeamSTEPPS in long-term care, including an instructor guide and training videos. Version 2.0 adds guidance on use of measures to assess initiatives and an updated evidence review.

Tools/Toolkit > Government Resource

TeamSTEPPS for Office-Based Care Version.

Rockville, MD: Agency for Healthcare Research and Quality; September 2017.

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.

Journal Article > Commentary

You can't blame the wreck on the train.

Potts JR III. Am J Surg. 2017;214:974-978.

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 > Study

Operative team communication during simulated emergencies: too busy to respond?

Davis WA, Jones S, Crowell-Kuhnberg AM, et al. Surgery. 2017;161:1348-1356.

Communication failures in the operating room are a well-recognized threat to patient safety. Researchers observed and analyzed communication across seven operating room teams during a simulated emergency using a closed-loop communication framework. They found that communication patterns varied by specialty and that the patient's clinical status influenced whether directed communication resulted in a response.

Journal Article > Commentary

Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error.

Ruedinger E, Olson M, Yee J, Borman-Shoap E, Olson APJ. Am J Med Qual. 2017;32:625-631.

Diagnostic error has yet to be formally integrated into graduate medical education. This commentary describes the design, implementation, and evaluation of a resident curriculum on diagnostic errors that explored medical decision making, critical thinking skills, and how to provide feedback and support for second victims.

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.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Journal Article > Review

Unprofessional behaviors among tomorrow's physicians: review of the literature with a focus on risk factors, temporal trends, and future directions.

Fargen KM, Drolet BC, Philibert I. Acad Med. 2016;91:858-864.

Disruptive and unprofessional behavior results in a poor culture of safety and may contribute to adverse events. This literature review sought to examine the incidence and types of unprofessional behaviors among medical students and residents. Although many studies show that trainees commit professionalism violations fairly regularly—for example, multiple studies show that up to 50% of residents falsify their duty hours—there was no clear evidence of an increase over time. The authors acknowledge that study of this area is impaired by lack of a standard definition and measurement strategy for unprofessional behavior and by a poor understanding of the relationship between professionalism violations and patient safety.

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.

  • Classic

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.

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