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Search results for "Health Care Executives and Administrators"

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Web Resource > Course Material/Curriculum

TeamSTEPPS 2.0 Core Curriculum.

Rockville, MD: Agency for Healthcare Research and Quality; September 2015.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

Journal Article > Study

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-1035.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.

Journal Article > Study

Elucidating reasons for resident underutilization of electronic adverse event reporting.

Hatoun J, Suen W, Liu C, et al. Am J Med Qual. 2016;31:308-314.

This survey study found that most resident physicians did not use incident reporting systems for adverse events in which they were involved, often because they did not know what or how to report. These results highlight the shortcomings of voluntary reporting for patient safety.

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.

Book/Report

Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings.

Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309288965.

This publication reports on a workshop that explored methods to engage patients and families in safety improvement efforts, including shared decision making and providing information to consumers about costs.

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

Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.

Batchelder AJ, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N. Anaesthesia. 2009;64:978-983.

A simulation-based teamwork training intervention for paramedics and physicians resulted in a reduction in errors during simulated out-of-hospital emergency situations.

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.

Book/Report

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

  • Classic

Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.

The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.

Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Meeting/Conference > Maryland Meeting/Conference

Patient Safety Certificate Program.

Armstrong Institute for Patient Safety and Quality. September 11-15, 2017; Constellation Energy Building, Baltimore, MD.

This course will cover various patient safety topics, including key concepts and human factors engineering strategies. The program will also explore the comprehensive unit-based safety program model of safety improvement. Participants will be engaged in problem-solving and developing patient safety initiatives.

Journal Article > Study

Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment.

Yaghmour NA, Brigham TP, Richter T, et al. Acad Med. 2017;92:976-983.

This retrospective cohort study found that the leading cause of death among resident physicians is cancer, and the second leading cause of death is suicide. Investigators note that there are fewer deaths overall and from suicide compared to age- and gender-matched general populations. They suggest monitoring and interventions to prevent burnout and provide support for medical trainees.

Journal Article > Commentary

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

Pradarelli JC, Thornton JP, Dimick JB. JAMA Surg. 2017 May 3; [Epub ahead of print].

This commentary explores the responsibility of organizations, device manufacturers, and clinicians for ensuring surgeon technical expertise in the use of robotic surgical equipment. The authors describe how hospitals and individual practitioners can enhance their capabilities with new technology to ensure safe patient care.

Journal Article > Commentary

Increasing patient safety event reporting in an emergency medicine residency.

Steen S, Jaeger C, Price L, Griffen D. BMJ Qual Improv Rep. 2017;6:u223876.w5716.

Technical and psychological factors can affect adverse event reporting. This quality improvement report highlights an effort to enhance resident reporting in an emergency department. Residents were educated about incident reporting and participated in feedback sessions every 2 months to improve their familiarity with the reporting system as well as augment their knowledge regarding how and what should be reported. The number and quality of reports increased following the intervention.

Newspaper/Magazine Article

Medical residents angered at extended work hours.

Hurt J. Med Econ. April 26, 2017.

Discussions about resident work hours generate debate regarding safety and physician burnout. This magazine article reports resident physician concerns about the shift hour changes that allow for flexible duty hours within a maximum 80-hour workweek.

Journal Article > Study

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017 Apr 25; [Epub ahead of print].

Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017 Apr 21; [Epub ahead of print].

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

Journal Article > Review

New graduate registered nurses' knowledge of patient safety and practice: a literature review.

Murray M, Sundin D, Cope V. J Clin Nurs. 2017 Mar 2; [Epub ahead of print].

This review spotlights the importance of closing the theory–practice gap for nurses just entering independent practice and discusses methods employed to address the potential for error during this transformative period.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

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