Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Health Care Executives and Administrators"

1 - 20 of 1135 results
  • Health Care Executives and Administrators
  • Physicians
Download Selected Citations

Show: 20 | 50 | 100

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 > 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

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 > Commentary

Aging gracefully? Patient safety advocates call for ongoing skills assessments for older physicians.

McKenna M. Ann Emerg Med. 2011;58:A15-A17.

This commentary suggests that emergency medicine adopt a mandatory retirement age and conduct ongoing skills assessment to ensure aging physicians can practice safely.

Meeting/Conference > Meeting/Conference Proceedings

Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety.

Institute of Medicine.

This Web site provides information on a national initiative to explore and evaluate the impact of resident work hours on patient safety, resulting in the Resident Duty Hours: Enhancing Sleep, Supervision, and Safety report. Periodic open meetings were held and information from those sessions is available on the site.

Perspectives on Safety > Perspective

Getting Into Patient Safety: A Personal Story

with commentary by Jeffrey B. Cooper, PhD, Reflections on the History of the Patient Safety Movement, August 2006

My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...

Audiovisual > Audiovisual Presentation

Shared Decision Making and Patient Safety: Making the Connections.

National Patient Safety Foundation. June 21, 2017; 1:00–2:00 PM (Eastern).

Shared decision making is gaining recognition as a way to improve patient understanding of their care options to enhance communication with their care team. This webinar will discuss shared decision making and informed consent as patient safety strategies.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Audiovisual > Audiovisual Presentation

Presenting TeamSTEPPS in the Perioperative Setting.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).

TeamSTEPPS is a process to enhance communication and teamwork in health care. This webinar will offer insights on implementing TeamSTEPPS in a large health system to improve perioperative practice. The session will highlight developing leadership as program champions, creating learning materials, and monitoring as tactics for sustaining improvements. This is part of a monthly series of educational modules on TeamSTEPPS.

Newspaper/Magazine Article

Two words can soothe patients who have been harmed: we're sorry.

Boodman SG. Kaiser Health News. March 15, 2017.

This news article reports on two incidents involving medical errors—one demonstrating the traditional shroud of secrecy and the other building on transparency and open disclosure—to illustrate the value of honest apology, discussion, and resolution of medical error for clinicians, patients, and families.

Book/Report

CMPA Good Practices Guide.

Ottawa, Ontario: Canadian Medical Protective Association; 2016.

Key patient safety topics include human factors, teamwork, adverse events, communication, professionalism, and risk management. This website provides resources regarding patient safety concepts, strategies for addressing risks, and guidance for faculty using the material.

Perspectives on Safety > Interview

In Conversation With… Mary Dixon-Woods, DPhil

Approaching Safety Culture in New Ways, March 2017

Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.

Perspectives on Safety > Annual Perspective

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Journal Article > Study

Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic.

Rattray NA, Sico JJ, Cox LM, Russ AL, Matthias MS, Frankel RM. Jt Comm J Qual Patient Saf. 2017;43:127-137.

Communication between inpatient clinicians and primary care physicians at the time of hospital discharge is often suboptimal, and it may not have improved with the advent of electronic health records. This qualitative study examined barriers to inpatient–outpatient communication in the care of stroke patients and found that clear communication is needed to ensure effective handoffs.

Journal Article > Study

Improving communication with primary care physicians at the time of hospital discharge.

Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

Journal Article > Study

Finding diagnostic errors in children admitted to the PICU.

Davalos MC, Samuels K, Meyer AND, et al. Pediatr Crit Care Med. 2017;18:265-271.

Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.

Journal Article

On Patient Safety.

Lee MJ. Clin Orthop Relat Res. 2013-2017.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and work hour reforms. Older materials are available online for free.

Journal Article > Commentary

Promoting civility in the OR: an ethical imperative.

Clark CM, Kenski D. AORN J. 2017;105:60-66.

The operating room is a complex environment that can affect clinicians' communication and teamwork behaviors. Describing a disrespectful encounter in the operating room, this commentary illustrates how such interactions can influence the safety of care delivery and highlights ways nurses can mitigate the situation, such as by raising concerns about disruptive conduct.

Journal Article > Commentary

You can't blame the wreck on the train.

Potts JR III. Am J Surg. 2016 Dec 21; [Epub ahead of print].

Insufficient supervision can limit resident education, which may increase risks to patient safety. This commentary outlines factors that reduce the effectiveness of general surgery resident supervision and provides suggestions to augment supervision, including developing policies that outline when resident supervision is required and educating hospital executives about the need for appropriate oversight of care delivered by trainees.

Back to Top