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 871 results
Download Selected Citations

Show: 20 | 50 | 100

Book/Report

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.

This book provides information about utilizing safety science and disseminating published evidence, staff knowledge, and other data to enable safety improvement and organizational learning from error.

Perspectives on Safety > Interview

In Conversation With… Sidney Dekker, MA, MSc, PhD

Update on Just Culture, September 2013

Professor Sidney Dekker has done revolutionary work on human error and safety and written several bestselling books on system failure and just culture.

Perspectives on Safety > Interview

In Conversation With… J. Bryan Sexton, PhD, MA

Update on Safety Culture, July-August 2013

J. Bryan Sexton, PhD, is director of the Patient Safety Center for the Duke University Health System and an international expert in safety culture and clinician burnout.

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.

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.

Book/Report

Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace.

Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254.

This book provides analysis from experts in high-risk industries regarding how cognition affects information sharing and team communication.

Tools/Toolkit > Government Resource

Surveys on Patient Safety Culture.

  • Classic

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

The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools and user guides. Hospitals can also use the AHRQ database to compare their Patient Safety Culture Survey results. In addition, an annual report summarizes the benchmarking data across more than 1000 hospitals nationwide. Poor staff perception of safety culture has been linked to increased error rates in hospitals. Culture has also been described as a key to establishing high reliability organizations. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Journal Article > Commentary

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

Kerfoot KM, Rapala K, Ebright P, Rogers SM. J Nurs Adm. 2006;36:582-588.

The authors describe the development of a patient safety initiative launched by a three-hospital system, its experience over 5 years, and plans for the future that emphasize the importance of embracing a partnership model.

Newspaper/Magazine Article

Overclocking the hospital.

Ho V, Patton S. CIO Asia. September 2006.

This article discusses computerized physician order entry implementation in US and Asian hospital systems and provides insight into selecting a system and achieving team commitment to the development process.

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.

Perspectives on Safety > Interview

In Conversation with…Jack Barker, PhD

Aviation and Patient Safety, January 2006

Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for a major airline. Dr. Barker began his career in the Air Force and proceeded to get his doctorate in cognitive psychology. His research has centered on high-performance teams, crew resource management (CRM), and training. He has trained hundreds of commercial airline pilots, as well as pilots and others working for NASA in the Space Shuttle program and Mars mission. His company, like several others, works with health care providers and organizations in an effort to translate aviation safety principles to health care.

Journal Article > Study

The long road to patient safety: a status report on patient safety systems.

  • Classic

Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.

To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005

A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005

In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...

Journal Article > Study

Making hospital care safer and better: the structure-process connection leading to adverse events.

El-Jardali F, Lagacé M. Healthc Q. 2005;8:40-48.

The authors propose a model for identifying factors that contribute to adverse events in hospital care. Using secondary data from a large Canadian nursing survey, the authors found that perceived understaffing, inadequate support services, and poor teamwork impacted the incidence of adverse events.

Journal Article > Commentary

Disseminating innovations in health care.

  • Classic

Berwick DM. JAMA. 2003;289:1969-1975.

This commentary and review discusses the ability to adopt growing numbers of evidence-based innovations as an ongoing challenge for health care industries. A leader in the field, Berwick examines Everett Roger's classic theory, Diffusion of Innovations, and research on the dissemination practice. Berwick provides an overview for both novices in the field and those engaged in implementing new innovations. The author offers a set of rules for disseminating innovations in health care, which include finding sound innovations, funding and supporting innovators, investing in early adopters, making early adopter activity observable, trusting and enabling reinvention, and leading by example. Although Berwick admits to the challenges ahead, he urges health care leaders not only to respect the change process but also to embrace it for a better future.

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 > Massachusetts Meeting/Conference

Patient Safety Executive Development Program.

Institute for Healthcare Improvement. September 7-13, 2017; The Charles Hotel, Cambridge, MA.

This program will educate participants about strategies and implementation plans to drive patient safety work. Featured faculty include Dr. Allen Frankel and Frank Federico.

Journal Article > Commentary

Using Kotter's change model for implementing bedside handoff: a quality improvement project.

Small A, Gist D, Souza D, Dalton J, Magny-Normilus C, David D. J Nurs Care Qual. 2016;31:304-309.

Change management has been described as a critical strategy to ensure safety improvements are sustained. This commentary discusses how one hospital applied a well-known change model to implement a new bedside handoff process and reports positive reactions from nurses and patients one month after the intervention.

Journal Article > Commentary

Improving safety for hospitalized patients: much progress but many challenges remain.

  • Classic

Kronick R, Arnold S, Brady J. JAMA. 2016;316:489-490.

Patient safety challenges and successes have emerged since the publication of To Err Is Human. This commentary discusses examples of progress such as the wide-scale use of the Comprehensive Unit-based Safety Program and the decrease of hospital-acquired conditions. The authors suggest that future efforts focus on improving measures of adverse events and diagnostic error research.

Back to Top