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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.

According to this study, many adverse drug event reports submitted by drug manufacturers to the Food and Drug Administration were incomplete. The authors advocate for the FDA to update their reporting requirements and compliance policies.

Journal Article > Study

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.

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Rajaram R, Chung JW, Kinnier CV, et al. JAMA. 2015;314:375-383.

Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare and Medicaid Services reduces payments to hospitals with the highest rates of these conditions. This analysis sought to assess the association between measures of hospital quality, such as accreditation, and penalties for HACs. Researchers found that accredited hospitals were more likely to incur HAC penalties. Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients. These results add weight to concerns about unintended consequences of pay-for-performance programs leading to widening health disparities and selective treatment, or "cherry-picking" of healthier patients. A related editorial co-authored by two United States Senators calls for including socioeconomic status in the HAC penalty formula.

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.

Book/Report

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.

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Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.

This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.

Book/Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2011.

Oakbrook Terrace, IL: The Joint Commission; September 2011.

This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.

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

2015 MHA Patient Safety and Quality Annual Report.

Okemos, MI: Michigan Health & Hospital Association; October 2015.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. Achievements covered in the current year include a reduction in patient readmissions and continued improvements in the incidents of central-line-associated bloodstream infections.

Book/Report

Hospital Reporting Program: Annual Summary.

Portland, OR: Oregon Patient Safety Commission.

This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.

Newspaper/Magazine Article

The rise of patient safety organizations.

Ivill DS, Kearbey AH. New York Law J. November 2, 2009.

This news feature discusses legal aspects of Patient Safety Organizations' (PSO) role in data collection and evaluation, work product designation, confidentiality protection, and organizational structure. In addition, the authors suggest key considerations to guide effective PSO implementation.

Book/Report

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

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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.

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.

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.

Journal Article > Study

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

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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...

Book/Report

Crossing the Quality Chasm: A New Health System for the 21st Century.

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Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2001. ISBN: 9780309072809.

Following up on the 1999 Institute of Medicine report, To Err is Human, this report outlines a strategy for improving quality through redesign of the entire health care system. This report famously points to six key aims of a high-quality health care system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. It is a call to action for providers and institutions as well as a strategic guide for clinicians, administrators, and policy makers regarding the changes needed to improve the quality of American health care.

Journal Article > Study

Relationship between state malpractice environment and quality of health care in the United States.

Bilimoria KY, Chung JW, Minami CA, et al. Jt Comm J Qual Patient Saf. 2017;43:241-250.

Medical malpractice law is intended to foster high quality care and discourage negligence among health care providers. This observational study took advantage of differing malpractice laws by state and examined the extent to which the malpractice environment is associated with hospital quality. Investigators assessed quality using several measures: validated processes-of-care measures, such as whether evidence-based actions were appropriately taken for common conditions like myocardial infarction, pneumonia, heart failure, and surgical care; patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems; imaging efficiency as reported by Medicare's Hospital Compare website; AHRQ Patient Safety Indicators; and 30-day readmission and hospital mortality rates. There were no associations between any of these quality outcomes and the rate of paid claims per 100 physicians. Areas with a higher malpractice geographic cost index had lower 30-day mortality but higher readmission rates, and higher malpractice costs were correlated with more inefficiency in some types of imaging. The authors conclude that malpractice environment does not appear to be associated with quality, but higher malpractice costs may lead to overtreatment.

Journal Article > Government Resource

Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.

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Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.

Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.

Journal Article > Commentary

Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System.

King HB, Kesling K, Birk C, et al. Mil Med. 2017;182:e1612-e1619.

The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.

Journal Article > Review

Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration.

Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Appl Clin Inform. 2017;8:12-34.

The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.

Book/Report

Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.

Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.

Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.

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