Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 17
- Education and Training 11
- Error Reporting and Analysis
- Human Factors Engineering 8
- Legal and Policy Approaches 10
- Logistical Approaches 5
- Quality Improvement Strategies 24
- Specialization of Care 1
- Teamwork 6
- Clinical Information Systems 4
- Transparency and Accountability 2
- Device-related Complications 2
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 9
- Drug shortages 1
- Failure to rescue 1
- Identification Errors 1
- Medical Complications 10
- Medication Safety 24
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 5
- Surgical Complications 13
- Internal Medicine 12
- Nursing 2
- Pharmacy 7
- Family Members and Caregivers 2
- Health Care Executives and Administrators 94
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
- Patients 17
- Australia and New Zealand 1
- Europe 25
- Canada 7
- United States of America 85
Search results for "Error Analysis"
- Error Analysis
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
Surgery is complex and involves a wide range of possibilities for error that can result in patient harm. This textbook explores both technical and organizational contributors to those factors. The authors provide context for how leaders can address weaknesses across all phases of surgical care to help improve safety. Topics covered include high reliability, teamwork, communication, and patient-centered culture.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.
Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
The primary focus on patient safety research has been in the hospital environment, but the majority of care is delivered in the ambulatory setting. This technical brief discusses the existing evidence on hospital-based safety interventions that have the potential to be implemented in ambulatory care. Strategies with moderate evidence include e-prescribing, pharmacist involvement, and hospital-to-ambulatory care transitions.
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.
Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.
This analysis found that scheduling problems among patients seeking primary care from Veterans Affairs health systems continue to occur. The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary care and spotlights the need to develop and disseminate a comprehensive policy for Veterans Affairs schedulers to reduce risk of scheduling errors.
Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders.
Sears K, Stockley D, Broderick B, eds. Aldershot, UK: Ashgate Publishing; 2015. ISBN: 9781472449276.
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
Historically, the approach to patient safety has been more reactive rather than proactive, involving a response to adverse events and near misses after they occur. This book covers two perspectives of safety: a reactive approach that emphasizes reducing adverse outcomes and a proactive approach that focuses on ensuring actions go as planned. The author discusses how each approach has been applied in health care and other high-risk industries. A PSNet perspective explored what health care can learn from aviation, another high-risk industry.
Youngberg BJ, ed. Jones & Bartlett Learning: Sudbuery MA; 2013. ISBN: 9780763774042.
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9781845621636.
Analyzing health care failures from 2004-2007 in the United Kingdom, this report identifies common themes and addresses how such investigations can guide improvement recommendations.
National Patient Safety Agency. London, UK: National Health Service.
These documents summarize National Patient Safety Agency incident reporting data from the first year of data collection. They are accompanied by workbooks for data review, slide sets and trends analysis.
Runciman B, Merry A, Walton M. London, UK: Ashgate Publishing; 2007. ISBN: 0754644359.
This book provides a four-part treatment on improving health care safety, featuring discussions on the weaknesses of the health care system, safety basics, error management, and error prevention.