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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
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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.

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. 

Journal Article > Commentary

Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems.

Clack L, Sax H. Ann Intern Med. 2017;166:HO2-HO3.

Poorly designed systems can contribute to human error. This commentary discusses how applying human factors engineering principles to the care environment can enhance clinician behavior and reduce health care–associated infections.

Journal Article > Study

Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.

Ancker JS, Edwards A, Nosal S, Hauser D, Mauer E, Kaushal R; HITEC Investigators. BMC Med Inform Decis Mak. 2017;17:36.

Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.

Journal Article > Study

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.

Journal Article > Commentary

Applying human-centered design thinking to enhance safety in the OR.

Criscitelli T, Goodwin W. AORN J. 2017;105:408-412.

Human-centered design is critical when producing innovations to improve patient safety. This commentary reviews how hospitals have applied design thinking to develop new processes to enhance safety in operating rooms.

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 > Commentary

Alarm fatigue: use of an evidence-based alarm management strategy.

Turmell JW, Coke L, Catinella R, Hosford T, Majeski A. J Nurs Care Qual. 2017;32:47-54.

Reducing nuisance alarms can address alarm fatigue and improve the safety of care. This commentary describes how one hospital utilized the Plan-Do-Study-Act model to design and implement an alarm monitoring strategy to decrease alarms and unnecessary continuous cardiac monitoring over a 2-year period. The authors summarize the results of the project and lessons learned.

Journal Article > Review

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-366.

Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.

Web Resource > Multi-use Website

Safety.

Center for Health Design.

Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.

Journal Article > Commentary

Understanding models of error and how they apply in clinical practice.

Garfield S, Franklin BD. Pharm J. June 14, 2016.

Human error and fallibility are a part of health care delivery that can be exacerbated by system failures. This commentary summarizes core concepts of human error and discusses how they can be applied to promote safety, transparency, and professionalism in pharmacy practice.

Newspaper/Magazine Article

Safety for all: integrated design for inpatient units.

Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.

Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for psychiatric patients must make unique considerations to protect this vulnerable population from harming themselves and other individuals that come into contact with them. This magazine article provides recommendations for hospitals to enhance room and fixture designs to reduce risks for mental health patients.

Journal Article > Study

Adverse events in robotic surgery: a retrospective study of 14 years of FDA data.

Alemzadeh H, Raman J, Leveson N, Kalbarczyk Z, Iyer RK. PLoS One. 2016;11:e0151470.

Using an automated natural language processing tool, this retrospective study evaluated adverse events related to robotic surgery reported between 2000 and 2013. Device malfunctions contributed to many incidents, thus understanding these technical difficulties will be important for avoiding future harms.

Journal Article > Study

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-933.

Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.

Journal Article > Study

Residents' numeric inputting error in computerized physician order entry prescription.

Wu X, Wu C, Zhang K, Wei D. Int J Med Inform. 2016;88:25-33.

Computerized provider order entry can improve medication safety, but numeric entry errors may still occur. This study found that numeric entry errors are more common in urgent situations and when numbers are entered from a main keyboard rather than a numeric keypad. This work underscores the importance of interface design in safety improvement efforts.

Newspaper/Magazine Article

At the hospital, better responses to those beeping alarms.

Landro L. Wall Street Journal. January 4, 2016.

Alert fatigue is a well-known problem in hospitals. This newspaper article reports on efforts to reduce unnecessary alarms in hospitals to prevent staff from overlooking critical alerts. Highlighting strategies such as using secondary notification systems and recalibrating alerts according to the severity of physiologic change, the article also describes organizational guidelines to improve alarm safety. A recent WebM&M commentary explored how alarm fatigue can result in patient harm.

Journal Article > Study

Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project.

Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. JMIR Hum Factors. 2016;3:e1.

In 2014, The Joint Commission added improving the safety of alarm systems as a National Patient Safety Goal. This study describes a quality improvement project to implement a change in default alarm settings and provide nursing education in a 20-bed transplant and cardiac intensive care unit. Although the alarm rate per patient day decreased from approximately 88 to 59 alerts, nursing attitudes toward alarms and maintaining best clinical practices did not change.

Book/Report

Medical Device Use Error: Root Cause Analysis.

Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.

Applying human factors engineering to examine mistakes associated with medical device use can lead to valuable learning opportunities. This publication discusses equipment use errors and provides information about utilizing root cause analysis (RCA) to identify weaknesses in device design that enable those mistakes. The book includes examples of RCAs to illustrate how the method can uncover flaws that contribute to error in various situations.

Journal Article > Review

Alarm fatigue: impacts on patient safety.

Ruskin KJ, Hueske-Kraus D. Curr Opin Anaesthesiol. 2015;28:685-690.

Alarm fatigue is a recognized safety concern in health care. Exploring factors that contribute to alarm fatigue, this review outlines technical, organizational, and educational approaches to managing its effect on care safety. A recent WebM&M commentary provides an overview of alarm fatigue and describes ways to enhance alarm safety.

Journal Article > Study

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.

Stevens AD, Hernandez C, Jones S, et al. Resuscitation. 2015;96:85-91.

This randomized simulation study compared paramedics' ability to correctly dose medications for pediatric patients with color-coded prefilled syringes versus traditional medication kits. Researchers found that color-coded prefilled syringes improved dose accuracy and decreased time to medication delivery, demonstrating how a system intervention can enhance clinical performance.

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