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- Communication Improvement 3
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Quality Improvement Strategies 3
- Technologic Approaches 2
Search results for "Primary Care"
- Primary Care
Journal Article > Study
Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.
Walter FM, Penfold C, Joannides A, et al. Br J Gen Pract. 2019;69:e224-e235.
This qualitative study of 39 patients with a recent diagnosis of brain tumor found that many had multiple primary care visits prior to diagnosis, raising concern for missed opportunities for diagnosis. Patients reported more prompt diagnosis when their primary care physician elicited a more comprehensive history including subtle cognitive changes. The authors conclude that better public awareness of symptoms could prompt more timely diagnosis of brain tumors.
Patient Safety Primers
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.
For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.
Cases & Commentaries
- Web M&M
Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH; November 2010
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
Journal Article > Study
Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.
DesRoches CM, Rao SR, Fromson JA, et al. JAMA. 2010;304:187-193.
Patient safety initiatives will increasingly balance the tension between systems change and individual accountability, and medical professionalism is often at the center of this discussion. Although certain behaviors in medical school predict unprofessional behavior, efforts to teach these skills have been described, particularly in addressing disruptive behavior. This study surveyed physicians and found that nearly 70% believe that it is their professional responsibility to report an impaired or incompetent colleague. However, of those with knowledge of such a colleague, 33% failed to report them to a relevant authority. Barriers to reporting included a belief that it wasn't their responsibility, nothing would happen from reporting them, and fear of retribution. A related editorial discusses medical professionalism in the context of this study's findings and weighs different strategies to address the challenges. A past AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.