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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Ambulatory computerized prescribing and preventable adverse drug events.

Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.

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.

Journal Article > Commentary

Why July matters.

Petrilli CM, Del Valle J, Chopra V. Acad Med. 2016;91:910–912.

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.

Journal Article > Commentary

Speak up! Addressing the paradox plaguing patient-centered care.

Mazor KM, Smith KM, Fisher KA, Gallagher TH. Ann Intern Med. 2016;164:618-619.

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.

Journal Article > Review

How safe is primary care? A systematic review.

  • Classic

Panesar SS, deSilva D, Carson-Stevens A, et al. BMJ Qual Saf. 2016;25:544-553.

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.

Journal Article > Study

Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study.

  • Classic

Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Ann Intern Med. 2016;164:1-9.

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.

Audiovisual > Audiovisual Presentation

2015 Rosenthal Symposium: Protecting Patients: Advances and Future Directions in Patient Safety.

National Academy of Medicine. December 10, 2015; National Academy of Sciences Building, Washington, DC.

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.

Book/Report

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.

  • Classic

Boston, MA: National Patient Safety Foundation; 2015.

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.

Journal Article > Commentary

Improving diagnosis in health care—the next imperative for patient safety.

  • Classic

Singh H, Graber ML. N Engl J Med. 2015;373:2493-2495.

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.

Journal Article > Study

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.

Hickner J, Smith SA, Yount N, Sorra J. BMJ Qual Saf. 2016;25:588-594.

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.

Journal Article > Study

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

Tariq A, Georgiou A, Raban M, Baysari MT, Westbrook J. BMJ Qual Saf. 2016;25:704-715.

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.

Web Resource > Course Material/Curriculum

TeamSTEPPS 2.0 Core Curriculum.

Rockville, MD: Agency for Healthcare Research and Quality; September 2015.

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.

Award > Award Announcement

2016 American Hospital Association–McKesson Quest for Quality Prize.

Chicago, IL: American Hospital Association and Health Research & Educational Trust.

This award program recognizes organization-wide commitment to the six key goals outlined in Crossing the Quality Chasm: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The 2016 honorees are Memorial Medical Center, Springfield, IL, Memorial Hermann Greater Heights, Houston, TX, and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA. The application process will reopen in early 2017. 

Journal Article > Review

Patient safety and end-of-life care: common issues, perspectives, and strategies for improving care.

Dy SM. Am J Hosp Palliat Care. 2016;33:791-796.

Exploring overlapping areas of concern in patient safety and end-of-life care initiatives, this review describes improvement strategies, such as team training and standardization of care, that apply in both domains.

Journal Article > Study

An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care.

Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. Anesth Analg. 2015;120:96-104.

In this before-and-after study, implementation of a checklist to improve handoffs between anesthesiologists led to better information transfer and enhanced provider satisfaction. These findings echo prior studies of structured handoff communication.

Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.

Book/Report

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309293099.

Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient settings, as their care involves exposure to high-risk medications and requires closely coordinated care. Seen in that light, this Institute of Medicine report, which bluntly concludes that the current system of cancer care is untenable, is particularly concerning. The report highlights numerous deficiencies in the current system, such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure to incorporate patient preferences into advanced care planning. To reshape how cancer care is delivered, the report recommends leveraging information technology to augment care coordination and real-time analysis of treatment data, better end-of-life planning, and improving communication with patients and families around prognosis and the risks and benefits of treatments. Multiple AHRQ WebM&M commentaries discuss safety issues in oncology patients, including a case of a chemotherapy medication error detected by the patient himself and a near-fatal error ascribed in part to poorly coordinated care.

Book/Report

Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings.

Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309288965.

This publication reports on a workshop that explored methods to engage patients and families in safety improvement efforts, including shared decision making and providing information to consumers about costs.

Book/Report

Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare.

Patankar MS, Brown JP, Sabin EJ, Bigda-Peyton TG. Burlington, VT: Ashgate; 2012. ISBN: 9780754672371.

This book presents a safety culture model as a tactic to assess and improve safety in health care.

Journal Article > Study

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

The Institute for Healthcare Improvement's 100,000 Lives Campaign generated national attention for galvanizing efforts to improve patient safety. This study found that executive leadership, midlevel staff, and frontline providers reported different perceptions about the campaign at their six participating hospitals. While respondents attributed only 58% of improvements to the campaign, all felt the interventions were sustainable, particularly with effective use of performance data and necessary leadership commitment. The findings also highlight the importance of aligning such initiatives with organizational culture to balance top-down and grassroots approaches.

Book/Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2011.

Oakbrook Terrace, IL: The Joint Commission; September 2011.

This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.

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