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Search results for "Health Care Executives and Administrators"

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Special or Theme Issue

Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability.

Health Serv Res. 2006;41:1535-1720.

This special issue includes articles on the application of high reliability organization (HRO) theory in health care, the role of sensemaking, HRO cultures, and policies that support reliability.

Meeting/Conference > Washington Meeting/Conference

ASHRM 2017 Annual Conference.

American Society for Healthcare Risk Management. October 15-18, 2017, Washington State Convention Center, Seattle WA.

This session will offer participants a range of educational opportunities that focus on how risk managers can contribute to safe and trusted health care. 

Meeting/Conference > New Jersey Meeting/Conference

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. September 21-22, 2017, Maggiano's Little Italy Hackensack, Hackensack, NJ.

This workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Journal Article > Study

A hybrid methodology for modeling risk of adverse events in complex health-care settings.

Kazemi R, Mosleh A, Dierks M. Risk Anal. 2017;37:421-440.

This study aimed to use modeling, a strategy to detect safety hazards, to characterize the risk of pressure ulcers and catheter-associated infections. Investigators developed a risk model that combined systems dynamics and Bayesian belief networks to assess organizational and nonorganizational factors that contribute to risks. The model performed well when validated against clinical data, suggesting wider applications of risk modeling may have practical patient safety applications.

Journal Article > Commentary

Deploying and measuring a risk and patient safety program.

Orel H, McGroarty M, Marchegiani H. J Healthc Risk Manag. 2017;36:26-33.

Risk management can contribute to proactive process improvement. This commentary describes the development and evaluation results of a long-term collaborative program to change risk management practice and reduce medical malpractice claims. Strategies utilized in the program included RiskRounds and web-based modules.

Journal Article > Commentary

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

Siedlecki SL, Albert NM. Clin Nurse Spec. 2017;31:23-29.

The ability to proactively identify and mitigate risk is key to safety improvement. This commentary describes several risk assessment tools available to develop estimates of potential adverse events and discusses how to ensure those assessments are valid and reliable.

Journal Article > Commentary

ACOG Committee Opinion #681: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2016;128:e257-e261.

Disclosure of errors and adverse events is now endorsed by a broad array of organizations. This statement discusses the importance of disclosure and provides resources to help health care organizations develop policies and programs that support a blame-free, learning approach to error that encourages reporting.

Journal Article > Study

Evidence-based guidelines for fatigue risk management in EMS: formulating research questions and selecting outcomes.

Patterson PD, Higgins JS, Lang ES, et al. Prehosp Emerg Care. 2016 Nov 18; [Epub ahead of print].

The impact of fatigue on clinician performance is a concern across health care settings. This study explained how researchers developed key questions to help assess fatigue in prehospital emergency medical services. They describe a plan to conduct systematic reviews to inform future guidelines.

Journal Article > Study

Case outcomes in a communication-and-resolution program in New York hospitals.

Mello MM, Greenberg Y, Senecal SK, Cohn JS. Health Serv Res. 2016;51(suppl 3):2583-2599.

Communication-and-resolution programs underscore the importance of early disclosure of medical error to patients and families. Prior research highlights implementation challenges associated with these efforts. Investigators analyzed 125 adverse event cases from 5 New York City hospitals over a 22-month period following the implementation of communication-and-resolution programs. The majority of cases did not involve substandard care, and disclosure occurred in more than 90% of cases.

Journal Article > Study

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.

  • Classic

Nguyen OK, Makam AN, Clark C, et al. J Gen Intern Med. 2017;32:42-48.

Identifying patients at high risk of readmission following hospital discharge is a patient safety priority. This observational cohort study found that patients with abnormal vital signs—temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation—upon hospital discharge were more likely to be readmitted to the hospital or die within 30 days compared to patients without vital sign abnormalities. The authors suggest vital signs should be used to assess safety for hospital discharge.

Journal Article > Study

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.

  • Classic

Robinson EJ, Smith GB, Power GS, et al. BMJ Qual Saf. 2016;25:832-841.

Patients admitted on the weekend may be at increased risk for complications and mortality. This analysis of a large national database examined variations in outcomes following in-hospital cardiac arrest by day versus night and weekday versus weekend. The investigators found that return of spontaneous circulation for 20 minutes or longer, a positive outcome, was more likely during weekday business hours compared with nights or weekends. Similarly, survival to hospital discharge was worse on nights and weekends. These results are consistent with prior studies that demonstrated worse outcomes for patients admitted to hospitals during nights or weekends. Raising concerns that patients who had in-hospital cardiac arrest on nights or weekends might have been more ill at baseline, a related editorial encourages rigorous evaluation of any staffing changes meant to address the weekend effect.

Journal Article > Review

Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review.

Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.

Prompt removal of intravenous catheters is critical to preventing health care–associated infections. This systematic review found that persistence of idle, or unused, catheters was associated with adverse outcomes. These findings highlight the need to develop and implement practices to reduce the incidence of idle catheters.

Journal Article > Study

Emergency medical services provider pediatric adverse event rate varies by call origin pediatric emergency care.

Jones D, Hansen M, Van Otterloo J, Dickinson C, Guise JM. Pediatr Emerg Care. 2016 Jul 12; [Epub ahead of print].

Emergency medical services may transport patients from the scene of an accident, an outpatient clinic, or a hospital. This study found that rates of adverse events and near misses were higher when pediatric patients came from accident scenes or clinics than if patients were transferred from other hospitals.

Journal Article > Study

An insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs.

Polinski JM, Moore JM, Kyrychenko P, et al. Health Aff (Millwood). 2016;35:1222-1229.

This intervention study provided pharmacist support to perform medication reconciliation and care coordination for patients discharged from the hospital. Compared to similar-risk patients who did not receive the intervention, those who had medication reconciliation by pharmacists were less likely to be readmitted to the hospital. These results add to the existing literature supporting the utility of pharmacist-led care transition interventions.

Journal Article > Review

Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.

Wolf ZR. J Infus Nurs. 2016;39:235-248.

Errors in administration of intravenous medications have potential to cause severe patient harm. This study analyzed medication administration errors voluntarily reported to the Institute for Safe Medication Practices. The investigator found that the most frequent error was excessive dosing and most errors were multifactorial, consistent with prior studies.

Journal Article > Commentary

TeamSTEPPS for health care risk managers: improving teamwork and communication.

Cooke M. J Healthc Risk Manag. 2016;36:35-45.

Hospitals utilize team training to improve clinician communication, coordination, and cross-disciplinary respect. This project explored the impact of a TeamSTEPPS-derived educational intervention for health care risk managers. The authors found that training focused on distinct professional groups generated strengthened perceptions of team structure and situation monitoring.

Journal Article > Commentary

Peer support for clinicians: a programmatic approach.

Shapiro J, Galowitz P. Acad Med. 2016;91:1200-1204.

Peer support programs can help clinicians cope with symptoms of burnout. This commentary describes a well-established program that emphasizes one-on-one counseling for vulnerable clinicians and offers insights on its development and structure. The authors provide specific steps toward initiating appropriate and effective support for clinicians when they need it.

Journal Article > Study

Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates.

  • Classic

Patrick SW, Fry CE, Jones TF, Buntin MB. Health Aff (Millwood). 2016;35:1324-1332.

Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.

Journal Article > Study

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability.

Manaseki-Holland S, Lilford RJ, Bishop JRB, et al; UK Case Note Review Group. BMJ Qual Saf. 2017;26:408-416.

Ascertaining whether adverse events are preventable is a continuing challenge in patient safety. Comparing two scales that assess preventability for mortality, this study found that there is high variability among experts rating the preventability of the same mortality event. These results suggest that preventability remains subjective despite attempts to define it in a reproducible fashion.

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