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Search results for "Latent Errors"
- Latent Errors
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
This report from the Department of Health and Human Services (HHS) describes a plan to bolster implementation of health information technology (IT) and reduce risks associated with its use. Building on recommendations of the Institute of Medicine report, Health IT and Patient Safety, the plan includes specific action items for HHS organizations and the private sector to augment health IT safety. Responsibilities will be shared across a number of HHS organizations: the Office of the National Coordinator (ONC), the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services. Goals involve making it easier for clinicians to report health IT–related incidents and hazards, encouraging reporting to Patient Safety Organizations, supporting the use of standardized forms in hospital incident reporting systems, and training surveyors to identify safe and unsafe practices associated with health IT. The Joint Commission has also contracted with ONC to better detect and address potential health IT–related safety issues across health care settings.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Geneva, Switzerland: World Health Organization; 2013. ISBN: 9789241505475.
This guide poses ethical questions for patient safety researchers to help them evaluate and prevent risks inherent in research design.
Sevdalis N. London, UK: The Health Foundation; June 2013.
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2013. ISBN: 9789289002943.
Exploring the value of engaging patients in their care, this report reviews successful interventions that involved patients in safety improvement efforts.
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.
This report highlights how working conditions can affect health care workers and recommends seven strategies for organizations to improve workplace safety.
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.
This report discusses the need for improved coordination and integration in patient care to reduce preventable errors.
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
Health care has been recently been directed toward focusing on the value of teamwork in reducing risks. This publication provides extensive information about team training, including key concepts, guidelines, insights from health care workers, and strategies to improve teamwork and monitor performance.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process.
Joseph A, Quan X, Taylor E, Jelen M. Concord, CA: Center for Health Design; 2012.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: The National Academies Press; 2012. ISBN: 9780309256810.
This report details the results of a workshop on health literacy in health care organizations.
Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0001.
This set of training materials provides techniques to help improve staff monitoring of nursing home residents' conditions to prevent delays and minimize harm.
Hofmann DA, Frese M, eds. New York, NY: Routledge Academic; 2011. ISBN: 9780805862911.
This book discusses the evidence regarding errors in organizations, including earlier efforts to manage human error and insights into broader system issues.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.