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- Culture of Safety 16
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- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 8
- Drug shortages 3
- Identification Errors 2
- Interruptions and distractions 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 8
- Nonsurgical Procedural Complications 1
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- Health Care Executives and Administrators 62
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Search results for "Latent Errors"
- Latent Errors
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. This workshop report reveals how health literacy affects patients' abilities to follow discharge instructions and makes recommendations to improve after-visit summaries to augment patient understanding of directions.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Manchester, UK: General Medical Council; November 2014.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
Washington, DC: Association of American Medical Colleges; 2014.
Studies have revealed a gap between what residents are expected to know and how prepared new interns are when they begin residency training, raising concern about patient safety during this period. These guides provide information for both faculty and students about key competencies that should be expected of new residents on their first day.
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC: Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
This report evaluates the implementation of a quality improvement initiative designed to characterize, track, and mitigate adverse events related to health information technology (IT). Investigators sought to determine challenges to engaging in identifying and addressing safety risks related to health IT in 11 health care organizations, and this publication outlines experiences and lessons learned from participating institutions. The authors call for greater awareness of safety risks related to health IT, better cooperation between risk management and health IT departments, identification of safety measures for health IT, incentives for health IT developers and vendors to improve health IT safety, and increased investment in risk management, health IT, and safety in ambulatory settings. The recommendations in this report serve as a blueprint for future practice and policy efforts to augment safety in the era of electronic health records.
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.
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
Charting Nursing's Future. Princeton, NJ: Robert Wood Johnson Foundation. Washington, DC: George Washington University School of Nursing. March 14, 2014;22:1-8.
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
When medical errors occur, patients desire full disclosure. This report calls for clinicians in the National Health Service to disclose errors that contribute to moderate or severe harm or death. The authors outline recommendations to help organizations establish a safety culture that requires discussion about unanticipated events and ensures that staff receive training in apologies.
Alexandria, VA: Department of Defense, Office of the Inspector General; February 21, 2014. Report No. DODIG-2014-040.
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Washington, DC: United States Government Accountability Office; February 10, 2014. Publication GAO-14-194.
London, UK: Point of Care Foundation; January 2014.
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013.
This white paper details how health care organizations can identify health information technology concerns and improve systems to reduce risks.
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.
This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Donchin Y, Gopher D, eds. New York, NY: CRC Press; 2013. ISBN: 9781466573628.
This publication uses case studies to explore human factors in health care and describes an approach to augment quality and prevent errors.
O'Hara J, Isden R. London, UK: Health Foundation; October 2013.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.