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Approach to Improving Safety
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Search results for "Health Care Executives and Administrators"
- Family Members and Caregivers
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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.
Journal Article > Commentary
Patient and family empowerment as agents of ambulatory care safety and quality.
Roter DL, Wolff J, Wu A, Hannawa AF. BMJ Qual Saf. 2017;26:508-512.
Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.
Journal Article > Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Journal Article > Study
Using an inpatient portal to engage families in pediatric hospital care.
Kelly MM, Hoonakker PL, Dean SM. J Am Med Inform Assoc. 2017;24:153-161.
This study found that parents of hospitalized children used the Internet-based patient portal and reported high rates of satisfaction. Parents perceived that the portal would reduce medical errors. This work suggests that engaging patients and caregivers via health-related Internet activities could support safe inpatient care.
Journal Article > Review
The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.
Gill FJ, Leslie GD, Marshall AP. Worldviews Evid Based Nurs. 2016;13:303-313.
Rapid response teams (RRTs) are a widely implemented safety intervention with a growing body of literature supporting their effectiveness. At some hospitals, families can activate the RRT if they are concerned. This systematic review identified successful implementation strategies for family-activated RRTs, but researchers found no clear evidence that this approach improves patient outcomes.
Perspectives on Safety > Interview
In Conversation With… Richard Kronick, PhD
Federal Organizations in Patient Safety, March 2016
Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013, and will be stepping down from the role this month. We spoke with him about AHRQ's efforts to develop measurements and implement improvements in patient safety.
Journal Article > Review
Evidence summary and recommendations for improved communication during care transitions.
Jackson PD, Biggins MS, Cowan L, French B, Hopkins SL, Uphold CR. Rehabil Nurs. 2016;41:135-148.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Audiovisual > Audiovisual Presentation
Improving Patient and Family Engagement in US Hospitals.
Health Research and Educational Trust. September 15, 2015.
Patient engagement in their care can contribute to both their individual safety and organizational improvement efforts. This webinar reviewed the results of a national survey on patient engagement efforts in hospitals and explored two hospitals' successful initiatives.
Journal Article > Study
Patient and family engagement: a survey of US hospital practices.
Herrin J, Harris KG, Kenward K, Hines S, Joshi MS, Frosch DL. BMJ Qual Saf. 2016;25:182-189.
This survey of acute care hospitals found significant variation for patient and family engagement activities. Most hospitals reported unrestricted visitor access, nearly two-thirds had formal error disclosure policies, and less than half had a patient advisory council. These findings demonstrate the gap between patient engagement recommendations and current hospital practice.
Book/Report
Partnering to Improve Quality and Safety: A Framework for Working With Patient and Family Advisors.
Chicago, IL: Health Research & Educational Trust; 2015.
Patient and family advisor programs have been implemented in health care as a way to incorporate the experiences of consumers into safety improvement work. This guide provides a framework to help hospitals develop partnership initiatives that focus on advisor recruitment, education, and teamwork to enhance efforts to engage patients and families in this role.
Journal Article > Study
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
- Classic
Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2015;24:203-211.
Allowing families to activate medical emergency teams (METs) may aid in the early detection of clinical deterioration. However, physicians have expressed concerns that families do not understand when an MET is necessary and that this responsibility could present an undue stress on family members. This study reports on the experience of family-activated MET calls over a 6-year period at an academic children's hospital. There were 83 family-activated MET calls, representing less than 3% of all MET responses at this hospital. Families most frequently requested METs for concerns regarding clinical deterioration, but less than one-quarter of these calls resulted in patients being transferred to an intensive care unit, compared to 60% of clinician-activated METs. Since families called METs only between one to two times per month, the program was not felt to pose a substantial burden. The authors also point out that some family-activated METs identified other clinically relevant information that may not have otherwise been shared with the primary clinical team, as well as important communication issues that could have led to adverse events.
Newspaper/Magazine Article
Patient- and family-centered care: error disclosure and investigation.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.
Patients are increasingly encouraged to take an active role in their own safety during hospital care. Describing a near miss of a medication error, this magazine article examines elements of effective disclosure and how engaging patients and their families can contribute to error investigations and safety improvement.
Journal Article > Commentary
Family-centered rounds.
Mittal V. Pediatr Clin North Am. 2014;61:663-670.
Family-centered rounds are multidisciplinary rounds that involve patients and their families, include the complete case presentation and discussion, and engage them in decision making. This commentary discusses how family-centered rounds can contribute to patient safety, such as better doctor–patient relationships, and barriers to implementing them, including perceptions that rounds would take longer.
Journal Article > Study
Parents' perspective on safety in neonatal intensive care: a mixed-methods study.
Lyndon A, Jacobson CH, Fagan KM, Wisner K, Franck LS. BMJ Qual Saf. 2014; 23:902-909.
This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.
Perspectives on Safety > Perspective
Patient Advocacy in Patient Safety: Have Things Changed?
with commentary by Helen Haskell, MA, Patient Advocacy, June 2014
This piece describes the evolution of the patient advocacy movement, including the events that spurred it, resulting reforms, and the impact of online access to medical information.
Journal Article > Study
Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.
Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
Journal Article > Study
Physician attitudes toward family-activated medical emergency teams for hospitalized children.
Paciotti B, Roberts KE, Tibbetts KM, et al. Jt Comm J Qual Patient Saf. 2014;40:187-192.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
Book/Report
Safety Is Personal: Partnering With Patients and Families for the Safest Care.
- Classic
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
Journal Article > Study
Structuring patient and family involvement in medical error event disclosure and analysis.
Etchegaray JM, Ottosen MJ, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.
Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.