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Search results for "Health Care Executives and Administrators"

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Journal Article > Commentary

Toward a safer health care system: the critical need to improve measurement.

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Jha A, Pronovost PJ. JAMA. 2016;315:1831-1832.

In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.

Book/Report

Patient Safety Culture: Theory, Methods and Application.

Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.

This publication covers patient safety culture including its background in high-risk industries, key concepts involved such as behavior change, measurement and assessment processes, and lessons learned from application and practice.

Journal Article > Study

Health care–associated infections among critically ill children in the US, 2007–2012.

Patrick SW, Kawai AT, Kleinman K, et al. Pediatrics. 2014;134:705-712.

This large cohort study of 174 hospitals examined rates of central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonias, and catheter-associated urinary tract infections in neonatal and pediatric intensive care units (ICUs) across the United States. Between 2007 and 2012, there were remarkable reductions in these hospital-acquired infections among critically ill infants and children. In pediatric ICUs, CLABSIs plummeted from about 4.7 to 1.0 per 1000 central-line days, while ventilator-associated pneumonias dropped from 1.9 to 0.7 per 1000 ventilator-days. The trends were similar in neonatal ICUs. The authors estimate that the decrease in CLABSI rates alone not only enhanced patient safety but also saved $131 million for these hospitals during the study period. A recent AHRQ WebM&M perspective focused on hospital infection prevention programs.

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.

Newspaper/Magazine Article

Medication administration errors in hospitals—challenges and recommendations for their measurement.

McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.

Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.

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.

Perspectives on Safety > Perspective

Strengthening the Business Case for Patient Safety

with commentary by Peter K. Lindenauer, MD, MSc, Pay-for-Performance: Implications for Patient Safety, May 2013

This piece discusses efforts to promote the business case for safety and quality in health care.

Journal Article > Commentary

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

Highlighting goals and strategies of the Partnership for Patients program, this commentary discusses challenges to improving patient safety.

Book/Report

Situational Awareness and Patient Safety: A Learning Package.

Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100.

This publication provides training to improve situational awareness and patient safety.

Book/Report

Safety Culture: Theory, Method and Improvement.

Antonsen S. Burlington, VT: Ashgate; 2009. ISBN: 9780754676959.

This book describes the fundamentals of safety culture in the context of well-known incidents in high-risk industries such as aviation, space exploration, and nuclear power.

Tools/Toolkit > Government Resource

Pediatric Quality Indicators Overview.

AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.

The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Pediatric Quality Indicators focus on quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

Book/Report

Advances in Patient Safety: New Directions and Alternative Approaches.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).

The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.

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.

Meeting/Conference > Washington Meeting/Conference

Learning From Never Events: Aligning an Organization Around Safety.

Virginia Mason Institute. September 27-29, 2017. Virginia Mason Institute, Seattle, WA.

This workshop will discuss enhancing safety culture through the identification and review of never events and an organization's 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.

Grant > Government Resource

Advancing Patient Safety Implementation Through Safe Medication Use Research (R18).

Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.

This funding program will support research demonstration projects that explore systemic strategies to enhance medication safety. The submission process for the program is now closed.

Journal Article > Study

Applying the high reliability health care maturity model to assess hospital performance: a VA case study.

Sullivan JL, Rivard PE, Shin MH, Rosen AK. Jt Comm J Qual Patient Saf. 2016;42:389-411.

High reliability organizations operate in high-hazard domains with consistently safe conditions. Through individual interviews, investigators determined that staff perceptions of patient safety largely matched their conceptual model of a high reliability health care organization and found two additional characteristics: teamwork and systems approaches to improvement. The authors suggest their model of high reliability organizations can be used to assess organizational reliability.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Journal Article > Study

A framework to assess patient-reported adverse outcomes arising during hospitalization.

Barbara O, Jose SM, Jayna HL, et al. BMC Health Serv Res. 2016;16:357.

Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.

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