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Search results for "Health Care Executives and Administrators"

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Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Maryland Meeting/Conference

TeamSTEPPS Master Training Course.

Johns Hopkins Armstrong Institute for Patient Safety and Quality. October 31-November 1, 2017; Constellation Energy Building, Baltimore, MD.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2017.

Harvard Medical School. October 16-17, 2017; Sheraton Boston Hotel, Boston, MA.

This workshop offers insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. This conference has expanded its scope beyond clinicians and patient safety officers to provide educational resources for pharmacists and nurses. Keynote speakers include James Conway and Dr. Thomas H. Lee.

Journal Article > Commentary

Investigating the causes of adverse events.

Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.

Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.

Journal Article > Commentary

Standardizing concentrations of adult drug infusions in Indiana.

Walroth TA, Dossett HA, Doolin M, et al. Am J Health Syst Pharm. 2017;74:491-497.

Standardizing drug concentrations addresses a medication safety concern for both adult and pediatric inpatients. This commentary describes a state-wide consensus project that reconciled existing lists of adult IV drug concentrations to develop a final list of 26 IV concentrations to reduce risks of medication errors.

Journal Article > Study

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

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 > Study

Safety of overlapping surgery at a high-volume referral center.

  • Classic

Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.

Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.

Journal Article > Commentary

Infusion medication error reduction by two-person verification: a quality improvement initiative.

Subramanyam R, Mahmoud M, Buck D, Varughese A. Pediatrics. 2016;138:e20154413.

Infusion pump programming is vulnerable to human error. This commentary describes how an improvement initiative tested a two-person verification strategy. Project leaders employed educational and feedback strategies along with plan-do-study-act cycles. The initiative resulted in reduced errors in pump programming and improvements in safety culture.

Journal Article > Study

Adverse event and error of unexpected life-threatening events within 24h of emergency department admission.

Zhang E, Hung SC, Wu CH, Chen LL, Tsai MT, Lee WH. Am J Emerg Med. 2017;35:479-483.

Trigger tools are frequently utilized to identify adverse events. The authors of this prospective study suggest that unexpected life-threatening events that occur within 24 hours of admission from the emergency department may be a useful trigger tool.

Audiovisual > Audiovisual Presentation

Using Just Culture to Improve Results on the AHRQ Hospital Survey on Patient Safety Culture.

Agency for Healthcare Research and Quality. November 9, 2016.

A just culture balances organizational context with appropriate accountability after an error. This webinar discussed how organizations can implement just culture principles to improve their results on the Hospital Survey on Patient Safety Culture.

Journal Article > Study

Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England.

  • Classic

Anselmi L, Meacock R, Kristensen SR, Doran T, Sutton M. BMJ Qual Saf. 2016 Oct 18; [Epub ahead of print].

Previous research has shown that patients admitted to the hospital on the weekend are at increased risk for worse outcomes, including mortality. This retrospective study examined more than 3 million emergency admissions to 140 hospital trusts in England between April 2013 and February 2014. Patient arrival times were recorded by day of the week and nighttime versus daytime. Using administrative data and standard risk adjustment, mortality rates were higher for patients arriving during the week on Wednesday and Thursday nights. Risk-adjusted mortality rates were also found to increase for patients arriving over the weekend from daytime on Saturday through nighttime on Sunday. However, when researchers adjusted for arrival by ambulance, higher mortality was statistically significant only for those patients arriving at the hospital during the day on Sunday. Investigators suggest that prior research supporting the weekend effect is overly reliant on administrative data, which may not accurately characterize illness severity. It is often debated whether the weekend effect could be due to factors related to the system of care (i.e., reduced staffing on weekends) or patient factors (i.e., increased severity of illness of patients admitted on the weekend). An Australian study sought to answer this question and found that certain diagnoses appeared to be associated with higher mortality for weekend admissions, largely due to health system factors.

Journal Article > Commentary

Patient experience must move beyond bad apples.

Hamedani A, Safdar B, Aaronson E, Lee TH. Ann Intern Med. 2016;165:869-870.

Patient safety leaders have long advocated for research to focus on how systems contribute to medical error. This commentary spotlights the need to apply the systems approach to enhance patient experience and suggests that doing so might improve physician engagement and help address burnout.

Web Resource > Multi-use Website

Radiotherapy Incident Reporting and Analysis System.

Center for Assessment of Radiological Sciences.

Patient Safety Organizations enable robust data collection and analysis to support learning from medical error. This website of a Patient Safety Organization dedicated to radiation safety improvement offers a mechanism for voluntary reporting of radiation oncology incident data, a searchable database, and related publications.

Meeting/Conference > Massachusetts Meeting/Conference

Diagnostic Error in Medicine 10th International Conference.

Society to Improve Diagnosis in Medicine. October 8-10, 2017, Boston Marriott Newton, Newton MA.

This annual conference will focus on the theme, "Improving Diagnosis: It Takes a Team" to drive work in reducing diagnostic errors. Featured speakers include Dr. Donald Berwick, Professor Amy Edmondson and Dr David Mayer.

Journal Article > Study

Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals.

Hauck KD, Wang S, Vincent C, Smith PC. Med Care. 2017;55:125-130.

The long-term consequences of patient safety problems can be difficult to quantify. This retrospective medical record review and modeling study estimated healthy life-years lost due to preventable adverse events such as venous thromboembolism, health care–associated infections, and deaths from low-risk procedures. The authors recommend using these estimates of long-term harm to prioritize prevention efforts.

Journal Article > Study

Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?

Chen Q, Rosen AK, Borzecki A, Shwartz M. Health Serv Res. 2016;51:2140-2157.

The AHRQ Patient Safety Indicators (PSIs) use hospitals' administrative data to measure quality and carry financial consequences for hospitals as part of pay-for-performance initiatives. Prior research has raised concerns about the validity of PSIs compared with directly using clinical data to identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from volume-based to harm-based weighting. Using data from 132 Veterans Health Administration hospitals, this retrospective study compared hospital performance using the previous PSI-90 with performance under the redesigned measure. Although there was strong association between the volume-based and harm-based PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of changes in the weights of the component measures. Approximately 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of pay-for-performance.

Book/Report

AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report.

Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.

The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in the nursing home setting. The 2016 user comparative database report summarizes survey data obtained from 12,395 staff and provider respondents working in 209 nursing homes. The report highlights two areas of safety culture in which nursing homes appear to do well: overall perceptions of resident safety and feedback and communication about incidents. Areas identified as needing improvement across most nursing homes included staffing issues and ensuring a nonpunitive response to mistakes. A previous PSNet perspective provided insights on safety culture.

Meeting/Conference > Government Resource

AHRQ Research Summit on Improving Diagnosis in Health Care.

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

PSO Program Briefs.

Agency for Healthcare Research and Quality.

Patient safety organizations (PSO) augment learning by sharing data from voluntary reporting and informing safety interventions. This series of articles discusses PSO-related programs that resulted in improvements, such as readmission reduction.

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