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- Communication Improvement
- Culture of Safety 2
- Error Reporting and Analysis 2
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 3
- Specialization of Care
- Teamwork 4
- Technologic Approaches 2
Search results for "Facility and Group Administrators"
Journal Article > Study
Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Am J Health Syst Pharm. 2007;64:850-854.
A limited number of guidelines promote best practices for medication reconciliation. This study describes the implementation of a standardized reconciliation process on an academic family medicine inpatient service. Using a newly designed form, investigators developed a system of shared ownership among nurses, pharmacists, and physicians that led to reductions in medication discrepancies. Data from more than 100 patients also demonstrated a reduction in the severity of discrepancies, although actual adverse events were not measured following discharge. Similar to published case studies, these findings provide a model for implementing a reconciliation process beyond the use of an electronic system or pharmacist-only intervention.
Special or Theme Issue
Frush KS, Hohenhaus SM, eds. Clin Ped Emerg Med. 2006;7:213-277.
This special issue provides 11 articles on various aspects of ensuring safety in pediatric emergency care, including the use of rapid response teams and family involvement in care.
Journal Article > Review
Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Arch Intern Med. 2006;166:955-964.
This systematic review evaluated 36 studies that encompassed pharmacy participation in patient rounds and medication reconciliation efforts as well as drug-specific pharmacist services. The authors detail the individual and collective findings, which include reductions in adverse drug events or errors in more than half the trials with improvements in medication adherence, knowledge, and appropriateness in a similar proportion. None of the studies demonstrated a worse overall outcome, and only one suggested increased health care utilization. The authors outline the needs for future investigation around roles for clinical pharmacists, clinical areas and patients most likely to benefit from their services, and better models to determine cost effectiveness.
Journal Article > Commentary
A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.
Weinstein L. Am J Obstet Gynecol. 2006;194:1160-1165; discussion 1165-1167.
The author provides background on the professional liability crisis and suggests that focus should be on changes to risk management, professional liability insurance, and the tort system.
McCarthy D, Blumenthal D. New York, NY: The Commonwealth Fund; April 2006.
This report presents ten case studies to illustrate interventions that address prominent and targeted areas for patient safety improvement. The five areas of focus include promoting an organizational safety culture, improving teamwork and communication, enhancing rapid response to inpatient crises, preventing health care–associated infections in intensive care units, and preventing hospital-based adverse drug events. The collection of stories represents a diverse group of health care organizations, with each sharing their approach to a given safety issue, the results achieved, and the lessons learned to assist others making similar efforts at their own institution. The authors also published an article about case studies in safety improvement.
Hua V. San Francisco Chronicle. February 17, 2006:B6.
This article reports on a study conducted by the Discrimination Research Center that found non-English speakers were not connected to a staff member who spoke the language in about half of calls to the emergency department.
Cases & Commentaries
- Spotlight Case
- Web M&M
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.
Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.