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- WebM&M Cases 4
- Study 15
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- Discontinuities, Gaps, and Hand-Off Problems 11
- Drug shortages 1
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- Medication Errors/Preventable Adverse Drug Events 38
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Health Care Providers
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Non-Health Care Professionals
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Search results for "Ambulatory Care"
- Ambulatory Care
Hertz BT. Med Econ. 2015;92:40-44.
Communication and response strategies have been shown to improve how organizations, clinicians, and patients and their families recover from adverse incidents. This news article discusses apology laws which protect certain statements regarding disclosure from being admissible in court and highlights how sensitivity to patients and transparent communication about the failure can be beneficial for both clinicians and patients after a medical error.
Whitaker P. New Statesman. August 2, 2019;148:38-43.
Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial intelligence, this news article cautions against the wide deployment of AI until robust evaluation and implementation strategies are in place to enhance system reliability. A recent PSNet perspective discussed emerging safety issues in the use of artificial intelligence.
Journal Article > Study
DesRoches CM, Bell SK, Dong Z, et al. Ann Intern Med. 2019;171:69-71.
Frakt A. New York Times. April 29, 2019.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
Journal Article > Commentary
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.
Leonard JB, Klein-Schwartz W. Am J Health Syst Pharm. 2019;76:264-265.
Patient and family medication administration mistakes can result in medication errors at home. This commentary describes the problem of "pill dumping," where patients combine their daily medicines into a spare vial. However, patients are at risk for mistakenly taking a vial of a single medication instead of their pill-dump vial and inadvertently overdosing. The authors suggest medication counseling and use of daily pill boxes as tactics to prevent this type of error.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Tools/Toolkit > Fact Sheet/FAQs
Horsham, PA: Institute for Safe Medication Practices; 2018.
This set of leaflets provides patients with information about taking high-alert medications safely.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Fetters A. The Atlantic. August 10, 2018.
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-profile accounts that raised awareness of challenges women experience in health care, this magazine article describes challenges to safe care such as lack of physician attention to patient concerns, misdiagnosis, and preconceptions regarding pain intensity.
Journal Article > Study
Mullen RJ, Curtis LM, O'Conor R, et al. Am J Health Syst Pharm. 2018;75:e213-e220.
Prior research has shown that patients with limited health literacy are at increased risk for misunderstanding the appropriate dosing of acetaminophen, a commonly used nonprescription medication that can cause acute liver failure after an overdose. In this study, researchers examined the risk of nonprescription acetaminophen misuse among 500 English-speaking patients across 4 outpatient clinics. They found that 39% of participants had limited health literacy and 54% had low visual acuity. Both reduced visual acuity and lower health literacy were independent risk factors for dosing errors and for insufficient understanding regarding the simultaneous use of multiple acetaminophen-containing products. An AHRQ Literacy Toolkit is available that provides a business case for interventions, educational tools, and guides for engaging patients in health literacy discussions. A previous WebM&M commentary discussed an incident involving confusion with acetaminophen dosing.
Journal Article > Study
Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.
Bell SK, Folcarelli P, Fossa A, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
Safety issues are common in the ambulatory care setting, but they can be difficult to detect because patients may spend months between contacts with the health care system. Engaging patients in their care is a recommended strategy to improve ambulatory safety and is the focus of a recent AHRQ toolkit. The OpenNotes initiative—in which patients have the opportunity to review and edit their medical records contemporaneously—aims to improve patient engagement and patient safety through promoting transparency. In this study, patients and caregivers with OpenNotes access were surveyed regarding the perceived effect of accessing notes on their understanding of their medical conditions and the patient–clinician relationship. Overall, most participants felt that accessing OpenNotes facilitated their understanding of the rationale for tests and referrals and improved their relationship with primary care providers. Although hindered by a low response rate, this study provides some support for the proposition that increased transparency can enhance patient engagement.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Boodman SG. Washington Post. December 9, 2017.
The prevalence of polypharmacy among older patients represents an important concern for health care safety, as unneeded medications can contribute to patient harm. This newspaper article reports on several strategies to reduce inappropriate medication use in older patients, including desprescribing and brown bag medication review.
Web Resource > Multi-use Website
Washington, DC: National Quality Forum.
Patient safety in ambulatory care is emerging as a focus of research, regulation, and measurement efforts. This website provides information and resources related to an initiative supporting expert review of current metrics, including prioritizing measures and identifying gaps in current performance measures.
Kast S. "On the Record." WYPR. October 31, 2017.
Diagnostic error continues to motivate improvement efforts in patient safety. This audio news segment discusses challenges that contribute to misdiagnosis, strategies to prevent diagnostic errors, and recommendations for patients to reduce risks such as preparing for appointments and asking questions.
Aleccia J, Bailey M. Kaiser Health News. October 26, 2017.
Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with hospice care, including poor coordination and insufficient family education, this news article discusses how citizen complaints led to government investigations into deficiencies of end-of-life home care.
Tools/Toolkit > Government Resource
Centers for Disease Control and Prevention.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.
Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.
Hobson K. Health Shots. National Public Radio. September 8, 2017.
Medication regimen nonadherence can result in patient harm. This news article reports the results of a national poll, which found that a substantial number of patients under the age of 35 do not take their medication as directed. Patients who stopped taking medications without consulting their doctors cited various reasons, including forgetfulness, feeling better, and belief the medication did not work .
Mickle K. Glamour Magazine. August 11, 2017.