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Education and Training
- Continuing Education
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Clinical Information Systems 4
- Transparency and Accountability 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 2
- Surgical Complications 1
Search results for "Continuing Education"
Journal Article > Review
Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review.
Whitehead NS, Williams L, Meleth S, et al. J Hosp Med. 2018;13:631-636.
Test results pending at the time of hospital discharge can lead to a delay in diagnosis and represent a significant patient safety risk. This systematic review found that certain electronic and educational interventions may improve documentation and awareness of pending test results. The authors suggest that further research is needed to understand how these interventions affect processes and outcomes.
Journal Article > Study
Advancing perinatal patient safety through application of safety science principles using health IT.
Webb J, Sorensen A, Sommerness S, Lasater B, Mistry K, Kahwati L. BMC Med Inform Decis Mak. 2017;17:176.
AHRQ's Safety Program for Perinatal Care used a multifaceted approach based on the comprehensive unit-based safety program to improve safety culture and perinatal outcomes at 46 hospitals. In this study, investigators conducted structured interviews to evaluate how participating hospitals used health information technology to enable implementation of the program. A variety of uses for health IT were described, including integration of checklists and standardized handoff tools into the electronic health record.
Journal Article > Commentary
Stark M, Fins JJ. Camb Q Healthc Ethics. 2014;23:386-396.
This commentary spotlights the importance of learning about cognitive science to understand and improve diagnostic reasoning in order to prevent errors. Underscoring limits of the Hippocratic Oath, the authors describe the ethical responsibility of individuals and organizations to augment clinical decision-making, judgment, and critical thinking skills as an integral component of professionalism.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Journal Article > Review
'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature.
Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-235.
Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.
Cases & Commentaries
- Spotlight Case
- Web M&M
Nils Kucher, MD; January 2006
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.