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- Error Reporting and Analysis 3
- Human Factors Engineering 2
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- Quality Improvement Strategies 7
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 4
- Medical Complications
- Medication Safety 5
- Psychological and Social Complications 1
- Surgical Complications 4
Search results for "Medical Complications"
- Credentialing, Licensure, and Discipline
- Medical Complications
Journal Article > Study
Kendall-Gallagher D, Blegen MA. Am J Crit Care. 2009;18:106-113.
Intensive care units with a higher proportion of certified registered nurses had lower rates of certain patient safety outcomes, including incidence of falls. Greater nursing experience also was correlated with lower rates of medication errors.
Journal Article > Study
Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals.
Pakyz AL, Wang H, Ozcan YA, Edmond MB, Vogus TJ. J Patient Saf. 2017 Apr 27; [Epub ahead of print].
Health care–associated infections (HAIs) are a preventable safety problem. This cross-sectional study looked at hospital factors related to HAI incidence. Investigators explored whether the Leapfrog Hospital Safety Score, a composite safety score calculated from publicly reported measures, is associated with HAIs. They also examined the incidence of HAIs in hospitals with Magnet status, conferred by a nurses' trade association in recognition of a positive nursing work environment. Lower Leapfrog safety scores were associated with more Clostridium difficile infections but no differences in other HAIs, and Magnet status was associated with lower rates of methicillin-resistant Staphylococcus aureus infection but worse than expected performance on C. difficile infections. These mixed results do not indicate a strong or consistent relationship between global measures of safety and quality and specific adverse events. A past PSNet interview with Leah Binder, President and CEO of The Leapfrog Group, discussed the development of the Hospital Safety Score.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Harasim P. Las Vegas Review-Journal. March 15, 2011:1A.
This newspaper article reports how a physician reused single-use equipment and put patients at risk for blood-borne diseases.
Cases & Commentaries
- Spotlight Case
- Web M&M
Eric S. Holmboe, MD; February 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
The 10 years since the release of the Institute of Medicine's To Err Is Human report have yielded some improvements in patient safety, but this Consumers Union report reminds clinicians and consumers alike that much work remains to be done. As the report notes, preventable safety problems such as medication errors and health care–associated infections still cause significant morbidity and mortality, despite the existence of effective preventive strategies. The report advocates for standardized measurement and public reporting of errors and calls for tighter accreditation standards for health care professionals.
Journal Article > Review
Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.
This review investigated outbreaks of hepatitis B and C virus in outpatient settings and found that transmission was uniformly caused by failures to follow basic principles of infection control.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.