Search results for "Health Care Executives and Administrators"

This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-­9 to ICD-­10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.

Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability in health care. This website collects evidence and existing tools to help organizations work toward high reliability, including the ORO 2.0 assessment tool to enable hospital leaders evaluate their culture, leadership, and performance.

Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.

This study describes the development of a tablet-based program that includes artificial intelligence elements for guiding patients through medication reconciliation. The researchers observed 10 patients using the tool and collected survey feedback on its usability and value from a small number of physicians, nurses, and patients.

For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.

Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient mortality increases during the July transition—truly exists. This commentary describes how leadership, supervision, mentor–learner pairings, and communication enhancement can help to reduce risks in this period. The authors suggest that applying strategies from aviation to augment teamwork between interns and residents could be an effective improvement strategy.

In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.

Patient participation is considered a key component of patient safety initiatives. This review examined patient engagement programs and policies and determined that the current methods do not result in true public involvement in safety improvement. The authors suggest broader strategies are needed to engage the public in co-designing a safer health care system.

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.

Although individual and organizational accountability are important elements of safety, they can also hinder system-wide improvement. This commentary discusses challenges to coordinating actions and accountability among and throughout the various components in health care, such as hospitals, governmental agencies, insurers, and accreditors. To achieve improvements, the authors propose that health care needs to establish a collective responsibility to develop collaborative solutions that balance global standards with local interventions.

According to this study, many adverse drug event reports submitted by drug manufacturers to the Food and Drug Administration were incomplete. The authors advocate for the FDA to update their reporting requirements and compliance policies.

Although patients have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions often have no system in place to ensure such concerns are promptly addressed. This commentary explores the disconnect between intention and action and suggests steps to be taken so that health systems can achieve benefits of patient engagement initiatives.

The surgical safety checklist has generally been evaluated based on outcomes that occur within 30 days of the primary operation. For instance, the initial studies by the World Health Organization showed remarkable improvements in mortality and morbidity within 30 days, while a more recent retrospective study following mandated implementation of the checklist throughout Ontario failed to show any enhanced safety outcomes over this same interval. This current study evaluated the introduction of a surgical safety checklist at a single academic Italian hospital, measuring 90-day all-cause mortality, length of stay, and 30-day readmission rates, in addition to 30-day mortality rates. The study included approximately 10,000 patients undergoing noncardiac surgery, with about half in the preintervention and postintervention groups. Following checklist implementation, 90-day mortality significantly decreased, 30-day all-cause mortality was unchanged, and adjusted length of stay dropped from 10.4 to 9.6 days; no difference was found in readmission rates. A recent PSNet interview with Dr. Lucian Leape explored the conflicting findings of the efficacy of surgical safety checklists.

This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.

Morbidity and mortality (M&M) conferences are a classic patient safety education and feedback strategy. This study found that elements of M&M conferences, including thorough investigation of failures, predicted whether an improvement initiative was implemented. This work suggests that M&M conferences can be optimally designed to foster subsequent improvement efforts.

Drug shortages have become increasingly common in recent years, especially in the United States. Some pediatric chemotherapeutics have frequently been in short supply, posing serious risks to patient safety. This commentary describes an ethical framework developed by a multidisciplinary group of experts and a panel of peer consultants. The framework seeks to guide clinicians' decision-making around allocating life-saving chemotherapies and associated drugs for children with cancer. The authors describe methods for managing shortages by reducing waste. The guideline also provides clear reasoning for actual prioritization across and within common pediatric cancers during a drug shortage. For example, in cases where shortages lead to the inability to provide the standard of care for some children, the authors propose emphasizing curability and prognosis in determining who is likely to have the most benefit. In 2013, the FDA released a strategic plan for preventing drug shortages, but the problem has continued largely unabated.

This narrative review found that factors associated with personality, attitudes, role ambiguity, and work environment all contribute to interpersonal conflict in health care settings. The authors describe possible interventions to reduce conflict, which should in turn improve patient safety.

This study expands on analyses and conclusions from published findings exploring the effects of moving to a new hospital with 100% single room accommodations. The researchers used nonequivalent controls by comparing results to a hospital that had not changed buildings but planned to do so (steady state control) and a hospital that moved to a new building with fewer than 50% single rooms (new build control). Falls, pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after the move to single rooms. However, there was also a significant change in the case mix on this ward following the move, which may have explained these changes in adverse events. On the acute assessment unit, falls and medication errors temporarily increased for the first 6 months but then returned to prior rates. The authors found neither clear evidence of benefit nor increased risk of harm attributable to moving to all single room accommodations.

Public ratings of hospital quality and safety data may not always provide the best information for patients and clinicians. This commentary discusses problems with the existing set of patient safety metrics and suggests that measurement approaches need to be improved to enhance transparency and decision making.

Patient safety in ambulatory care settings has received less attention than in the hospital setting, where the patient safety movement originated. This systematic review commissioned by the World Health Organization examined patient safety incidents in primary care. Estimates diverged widely between studies, and most patient safety incidents did not lead to harm. However, the types of incidents most likely to cause harm were missed and delayed diagnoses and medication prescribing problems. The accompanying editorial highlights the need to implement consistent and clear definitions for patient safety incidents and associated harm and advocates for investment in research and improvement efforts for patient safety in primary care.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This cohort study examined treatment patterns for patients who had experienced a nonfatal opioid overdose. More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17% of those patients experienced another overdose event. An accompanying editorial notes the lack of systems to ensure clinicians' awareness of patients' opioid overdoses and recommends enhancing training and support so that clinicians are prepared to treat chronic pain and addiction. New approaches are urgently needed given this crisis in medication safety. A previous WebM&M commentary discussed the challenges of prescribing safely for chronic opioid users.

In recognition of the 15th anniversaries since To Err Is Human and Crossing the Quality Chasm were published, this symposium discussed accomplishments and persisting challenges in the fields of patient safety and quality improvement since those reports were released. The session featured Dr. Donald Berwick, Dr. Lucian Leape, and Carolyn Clancy as speakers.

Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.

Measuring patient safety for individual hospitals and health systems remains a challenge. Incident reports provide one lens into patient safety, despite concerns about under-reporting. Numerous incident reports may indicate either a high number of errors or a robust safety culture that encourages blame-free event reporting. Therefore, it is unclear whether the volume of incident reports should serve as a patient safety metric. In this study, investigators analyzed all incident reports from the national reporting system in the United Kingdom and determined that hospitals with fewer litigation claims had more incident reports. They found no association between mortality or patient satisfaction and number of reports, and more incident reporting took place where survey results indicated a positive safety culture. These findings suggest that having a high quantity of incident reports does not signify an error-prone environment, and the authors recommend against using incident reporting rates as a quality metric. A past PSNet perspective discussed incident reporting systems as tools for improving patient safety.

Middle managers have a key role in successful improvement efforts, but engaging them in these activities can be challenging. This narrative review describes a model that involves middle managers and frontline clinicians in multidisciplinary teams to augment implementation of quality improvement interventions.

This report provides an objective assessment of the state of the safety field 15 years after the release of the Institute of Medicine's To Err Is Human. Acknowledging that progress has been slower than anticipated, the report makes eight recommendations for achieving total system safety, including creating a common set of safety metrics that reflect meaningful outcomes, establishing and sustaining a culture of safety, centralizing oversight of patient safety at the national level, improving the safety of information technology, and supporting patients, families, and the health care workforce. The report also highlights the need for greater investment in patient safety, particularly in the outpatient and long-term care areas. Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), discussed the evolving responsibilities of NPSF in a 2014 PSNet interview.

The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.

When patients already designated as hospitalized remain as boarding in the emergency department, it poses a challenge for staff workflow as well as safety concerns for patients. This case-control study identified missed care and delayed care more frequently for boarded patients than other emergency department patients, adding to the criticism of this common practice.

A key goal of patient safety improvement is preventing error, but challenges remain in distinguishing which harms are preventable. Discussing approaches to measuring preventable harm related to patient mortality, this commentary highlights limitations of hospital standardized mortality ratios as a quality measure and suggests combining multiple metrics designed with the complexity of health care in mind to uncover quality issues.

The National Academy of Medicine report, Improving Diagnosis in Health Care, estimated that most US adults will experience one or more diagnostic errors in their lifetimes. Summarizing the goals from the report, this commentary details how the recommendations can lead to enhanced diagnostic safety and reduced patient harm. The authors also acknowledge potential challenges to implementing the systems and process changes described.

Even in the era of electronic prescribing, look-alike and sound-alike drug names remain a safety vulnerability. In 2007, the Food and Drug Administration adopted Tall Man lettering, in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication (e.g., DOPamine; DOBUTamine). Despite widespread use of Tall Man lettering, it is unclear whether this strategy reduces errors. In this interrupted time series analysis, investigators pre-specified 12 look-alike, sound-alike drug errors in pediatric medication use and examined whether the frequency of these errors changed after Tall Man lettering was introduced. Although such errors were rare to begin with, they found no reduction after implementation of Tall Man lettering. This finding suggests that other interventions should be explored to avoid look-alike and sound-alike drug errors. This research also demonstrates the importance of evaluating safety interventions, which may have minimal impact despite face validity.

Although heath information technology (IT) has improved patient safety, studies have shown that implementing electronic health records can introduce new errors. This study examined closed malpractice claims related to health IT. Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally designed to support safety in those settings. Cases involving medication errors, diagnostic errors, or treatment complications were almost equally prevalent, indicating that health IT vulnerabilities span multiple tasks and functions. Software design issues and implementation problems also played a role in these incidents. These findings emphasize the need to reexamine health information technologies and how they are implemented in health care systems to enhance safety. A recent PSNet perspective examined challenges in health IT implementation, and another perspective discussed the need for innovations in health IT usability.

Defensive medicine—the practice of performing potentially unnecessary procedures or diagnostic tests to avoid the threat of malpractice liability—is thought to contribute to high health care costs in the United States. Because procedures and tests carry risks of complications, defensive medicine also may lead to adverse events. This secondary data analysis examined prospectively whether physicians who performed more cesarean deliveries (considered to be defensively motivated) were more or less likely to be subject to malpractice claims compared with those performing fewer cesarean deliveries. Researchers adjusted for available clinical characteristics and still found that obstetricians who performed more cesarean deliveries were less likely to have subsequent alleged malpractice incidents. This finding suggests that defensive medicine may be a rational physician response to the current malpractice environment, and underscores the patient safety rationale for malpractice reform. A previous WebM&M commentary discusses the causes and consequences of defensive medicine.

The unintended consequences related to implementation of health information technologies have been widely documented. In this commentary, the authors offer insights regarding a government-funded investigation of 10 computerized provider order entry systems, discuss weaknesses in these systems, and make recommendations to focus on designing around human factors, enhancing workflow, and improving reporting.

In this study, researchers developed a system for surgical time-outs where scanning a patient's wristband launches a presentation on the operating room monitor, which includes a video of the patient stating his or her name, date of birth, surgical procedure, and operative laterality. Although these took longer than standard timeouts (79 seconds versus 49 seconds), 87% of operating room personnel preferred the digital version, and performance of key safety elements significantly improved.

Medication errors in the hospital have been studied, quantified, and systematically evaluated for potential solutions. A notable exception is the perioperative setting, where medications given by anesthesiologists often bypass standard safety checks. This study is the largest prospective observational study of anesthesia-related medication events available to date. At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed. Approximately 1 in 20 perioperative medication administrations resulted in a medication error or adverse drug event; 80% of these errors were deemed preventable. None of the errors resulted in death, but 2% were considered life-threatening. There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists. The study took place at an academic hospital with substantial local expertise in medication safety, where operating rooms already used a barcode-assisted syringe labeling system. An accompanying editorial suggests that medication error rates may therefore be even higher in other settings and community hospitals.

Studies of safety culture have consistently found that management has more positive perceptions of safety than frontline workers. This analysis of data from the AHRQ Medical Office Survey on Patient Safety Culture explored this finding in greater depth. The study examines the specific areas where perceptions of safety diverged between medical office management, physicians, and staff from more than 800 clinics. The investigators found that staff (including physicians and nurses) had markedly lower perceptions of the quality of staff training in patient safety and the openness of communication around safety issues compared with management. Consistent with other studies, management also had a much higher perception of overall safety than staff. As high reliability organizations rely on shared goals and open communication to ensure situational awareness, variations in perceptions of safety culture across professional roles will impair an organization's ability to address safety issues.

This qualitative study of medication prescribing practices at long-term care facilities uncovered multiple safety hazards, including inadequate handoffs, insufficient information flow, and lack of a robust safety culture. The results suggest that both systems approaches and team training are needed to improve medication safety in long-term care facilities.

Disrespectful behaviors in health care have been found to have serious effects on nurses, physicians, and trainees. This review explores how experiences with bullying and undermining affect surgical trainees in the National Health Service and outlines recommendations to address the issue at national, organizational, and local levels.

This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.

Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.

This publication features interviews with leaders in patient safety to capture insights on their motivation and how they see the future of quality improvement in health care. Interviewees include Sidney Dekker, Erik Hollnagel, René Amalberti, and Charles Vincent.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Delayed diagnosis of infectious disease can negatively affect patients, care teams, and public health. Reviewing insights from a panel analysis of the well-known incident involving delayed diagnosis of Ebola virus, this report highlights the need to improve information transfer and emergency department safety culture to enhance diagnostic and infection prevention processes.

This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

Disruptive physician behavior is a recognized patient safety problem. Fear of confrontation with a disruptive individual may inhibit speaking up about potential errors and worsen safety culture and teamwork. In this simulation study, neonatal intensive care unit teams were exposed to either rude or neutral comments from an observer during their assigned simulated task. Compared to teams receiving neutral comments, those who were exposed to rudeness performed worse. This study complements prior studies which document perceived consequences of disruptive behavior by demonstrating worse simulated task performance. This work also reveals that rudeness external to a team can affect performance and suggests that a polite work culture would foster patient safety.

The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.

Shared mental models can augment decision-making and teamwork during stressful situations. This commentary explores the role of shared mental models in medical emergency teams (METs) and describes a team development approach to enhance performance of MET members and improve patient outcomes.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.