Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Health Care Executives and Administrators"

1 - 20 of 237 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Ambulatory computerized prescribing and preventable adverse drug events.

Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.

Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.

Book/Report

Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report.

Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.

For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.

Journal Article > Review

How safe is primary care? A systematic review.

  • Classic

Panesar SS, deSilva D, Carson-Stevens A, et al. BMJ Qual Saf. 2016;25:544-553.

Patient safety in ambulatory care settings has received less attention than in the hospital setting, where the patient safety movement originated. This systematic review commissioned by the World Health Organization examined patient safety incidents in primary care. Estimates diverged widely between studies, and most patient safety incidents did not lead to harm. However, the types of incidents most likely to cause harm were missed and delayed diagnoses and medication prescribing problems. The accompanying editorial highlights the need to implement consistent and clear definitions for patient safety incidents and associated harm and advocates for investment in research and improvement efforts for patient safety in primary care.

Journal Article > Study

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.

Hickner J, Smith SA, Yount N, Sorra J. BMJ Qual Saf. 2016;25:588-594.

Studies of safety culture have consistently found that management has more positive perceptions of safety than frontline workers. This analysis of data from the AHRQ Medical Office Survey on Patient Safety Culture explored this finding in greater depth. The study examines the specific areas where perceptions of safety diverged between medical office management, physicians, and staff from more than 800 clinics. The investigators found that staff (including physicians and nurses) had markedly lower perceptions of the quality of staff training in patient safety and the openness of communication around safety issues compared with management. Consistent with other studies, management also had a much higher perception of overall safety than staff. As high reliability organizations rely on shared goals and open communication to ensure situational awareness, variations in perceptions of safety culture across professional roles will impair an organization's ability to address safety issues.

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.

Tools/Toolkit > Government Resource

Prevention Quality Indicators Overview.

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

The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators use hospital admissions data to screen for potential quality lapses on conditions that generally don't require hospitalization if managed effectively at the primary care level.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Patient safety incidents are common in primary care: a national prospective active incident reporting survey.

Michel P, Brami J, Chanelière M, et al. PLoS One. 2017;12:e0165455.

This prospective study elicited incident reports from general practitioners for all types of adverse events occurring in primary care. Most events were judged to be preventable, and incidents were frequently due to the organization of care rather than from knowledge gaps on the part of physicians. These results underscore the need to focus on organizational factors in primary care to improve patient safety.

Journal Article > Study

Improving communication with primary care physicians at the time of hospital discharge.

Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

Journal Article > Study

Screening for medication errors using an outlier detection system.

Schiff GD, Volk LA, Volodarskaya M, et al. J Am Med Inform Assoc. 2017;24:281-287.

Medication errors continue to occur despite implementation of computerized provider order entry and clinical decision support systems. This study sought to assess whether medication error alerts might have a greater impact on mitigating such errors if they were generated based on outlier detection screening. Researchers analyzed data from the electronic health records of 747,985 outpatients to identify outliers that might indicate a medication error. They then chose 300 charts from the 15,693 resulting alerts. The charts were reviewed using a coding system to evaluate the utility of the alerts generated. About 75% of the chart-reviewed alerts created by the screening system identified possible medication errors. The authors suggest that using this type of outlier detection screening to generate alerts might improve existing clinical decision support systems' ability to mitigate medication errors. A prior WebM&M commentary discussed an incident involving an electronic prescribing error.

Book/Report

Technical Series on Safer Primary Care.

Geneva, Switzerland: World Health Organization; 2016.

Much of patient safety research has focused on the hospital setting, but a majority of health care is delivered in the ambulatory setting. This collection explores key safety topics in the primary care environment: patient engagement, education and training, human factors, administrative errors, diagnostic errors, medication errors, multimorbidity, care transitions, and electronic tools. Each monograph provides an introduction to each area of concern and practical approaches to improvement.

Journal Article > Commentary

Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project.

Schiff GD, Reyes Nieva H, Griswold P, et al. Health Serv Res. 2016;51(suppl 3):2634-2641.

Prior research has shown that malpractice risk in the outpatient setting is significant and that claims frequently involve missed and delayed diagnoses. This editorial describes lessons learned from the Massachusetts PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) project. Funded by the Agency for Healthcare Research and Quality, the PROMISES project involved a multipronged intervention within 16 randomly selected primary care practices to address known areas of risk in ambulatory care, including test result management, referrals, medication management, and communication issues. A previous PSNet perspective discussed how research may help improve the malpractice system.

Book/Report

Patient Safety in Ambulatory Settings.

  • Classic

Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care and notes that studies on patient engagement and diagnostic error are lacking.

Journal Article > Study

Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.

Linzer M, Poplau S, Brown R, et al. J Gen Intern Med. 2017;32:56-61.

Burnout among clinicians is a widespread patient safety concern. This study compared usual outpatient medical care to an intervention designed to improve clinician working conditions, with the aim of reducing medical errors and enhancing performance on a bundle of care quality measures. The intervention included an assessment of clinician perceptions of working conditions and well-being followed by a locally designed quality improvement project. Each clinic designed an intervention to address the concerns that arose from the assessment. Some clinics chose to work on improving communication or team-based chronic disease management while others focused on redesigning the clinic workflow. Investigators randomized 34 clinics either to receive the intervention or to continue their usual practice and found no differences in medical error rates or care quality measures between the clinics. The authors determined that reducing clinician burnout may not necessarily enhance patient safety and conclude that longer-term, standardized improvement interventions may be needed to augment health care quality.

Book/Report

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.

Carson-Stevens A, Hibbert P, Williams H, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

Management and analysis of incident reporting data must be enhanced in order to realize the potential for learning and improvement from reporting activities. This publication explored primary care incidents reported in England and Wales over an 8-year period. Investigators found inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred. Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system improvements needed to optimize incident reporting as a patient safety improvement strategy.

Book/Report

Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.

Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.

Bibliography

Annotated bibliography: understanding ambulatory care practices in the context of patient safety and quality improvement.

Montano MF, Mehdi H, Nash DB. Am J Med Qual. 2016;31(suppl 2):29S-43S.

The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.

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 > Review

Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials.

Clyne B, Fitzgerald C, Quinlan A, et al. J Am Geriatr Soc. 2016;64:1210-1222.

Older patients are more vulnerable to adverse drug events, and a key safety strategy is to avoid prescribing high-risk medications to these patients. This systematic review found that pharmacist medication review and clinical decision support, as well as combined approaches, were modestly effective at reducing high-risk prescribing for older patients. The authors suggest that further studies are needed to identify more effective means of promoting safe prescribing for this vulnerable population.

Journal Article > Study

Medication complexity, medication number, and their relationships to medication discrepancies.

Patel CH, Zimmerman KM, Fonda JR, Linsky A. Ann Pharmacother. 2016;50:534-540.

This study found that higher medication regimen complexity, as measured by the Medication Regimen Complexity Index, was associated with more medication discrepancies among primary care patients. These results are consistent with prior studies showing that individuals who take more medications have a higher risk of adverse drug events.

Back to Top