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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 4
- Legal and Policy Approaches 3
- Policies and Operations
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Transparency and Accountability 1
Search results for "Policies and Operations"
- Policies and Operations
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
This workbook includes background on disruptive behaviors and provides tools for health care managers to develop awareness initiatives and policies to reduce the impact and occurrence of such behavior.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Medication safety is a concern in various settings across an organization. This white paper discusses the role of a medication safety officer to oversee reporting and analysis of medication errors and coordinate improvement efforts. Responsibilities of a medication officer include serving as a champion, advocating for safety interventions, and helping implement system changes.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
Hospital patient and family advisory councils can help inform development of patient-centered safety initiatives. This report discusses characteristics of hospital-based patient and family advisory councils in the state of New York and outlines best practices for implementation to engage patients and families in quality and safety improvement.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. This report assesses management of claims against National Health Services trusts to determine the costs involved, ensure appropriate patient compensation, and control incidence of future claims through collaborative care improvement efforts.
Disclosure of unanticipated events: creating an effective patient communication policy (part 2 of 3).
Chicago, IL: American Society of Healthcare Risk Management; 2003.
The process for crafting a policy to support effective disclosure initiatives is reviewed. Discussion includes a summary of the key document elements and highlights legal considerations.