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 513 results
  • Health Care Executives and Administrators
  • Pediatrics
Download Selected Citations

Show: 20 | 50 | 100

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 > Commentary

An ethical framework for allocating scarce life-saving chemotherapy and supportive care drugs for childhood cancer.

Unguru Y, Fernandez CV, Bernhardt B, et al. J Natl Cancer Inst. 2016;108:djv392.

Drug shortages have become increasingly common in recent years, especially in the United States. Some pediatric chemotherapeutics have frequently been in short supply, posing serious risks to patient safety. This commentary describes an ethical framework developed by a multidisciplinary group of experts and a panel of peer consultants. The framework seeks to guide clinicians' decision-making around allocating life-saving chemotherapies and associated drugs for children with cancer. The authors describe methods for managing shortages by reducing waste. The guideline also provides clear reasoning for actual prioritization across and within common pediatric cancers during a drug shortage. For example, in cases where shortages lead to the inability to provide the standard of care for some children, the authors propose emphasizing curability and prognosis in determining who is likely to have the most benefit. In 2013, the FDA released a strategic plan for preventing drug shortages, but the problem has continued largely unabated.

Journal Article > Commentary

Crib of horrors: one hospital's approach to promoting a culture of safety.

Korah N, Zavalkoff S, Dubrovsky AS. Pediatrics. 2015;136:4-5.

Games illustrating what could go wrong can reveal insights into culture and teamwork in a health care organization. This commentary describes a low-tech simulation activity in a pediatric setting designed to foster learning by engaging staff to identify, correct, and discuss safety hazards.

Journal Article > Study

A trigger tool to detect harm in pediatric inpatient settings.

  • Classic

Stockwell DC, Bisarya H, Classen DC, et al. Pediatrics. 2015;135:1036-1042.

Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.

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.

Legislation/Regulation > Organizational Policy/Guidelines

Metric units and the preferred dosing of orally administered liquid medications.

Neville K, Galinkin JL, Green TP, et al; Committee on Drugs of the American Academy of Pediatrics. Pediatrics. 2015;135:784-787.

Accidental overdoses can occur when oral medications are given to children using teaspoons as measurement devices. This policy statement recommends use of milliliter-based dosing devices to enable metric-based administration of liquid medications to pediatric patients.

Journal Article > Study

Safety and diagnostic accuracy of tumor biopsies in children with cancer.

Interiano RB, Loh AHP, Hinkle N, et al. Cancer. 2015;121:1098-1107.

This study sought to evaluate the safety and diagnostic accuracy of biopsies in pediatric patients with cancer. Analysis of biopsy procedures in children with suspected cancer over a 10-year period found few safety incidents and a low risk of diagnostic error.

Tools/Toolkit > Government Resource

Pediatric Quality Indicators Overview.

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

The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Pediatric Quality Indicators focus on quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

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

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

Rosen M, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.

This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.

Journal Article > Study

Overdose risk in young children of women prescribed opioids.

Finkelstein Y, Macdonald EM, Gonzalez A, Sivilotti MLA, Mamdani MM, Juurlink DN; Canadian Drug Safety And Effectiveness Research Network (CDSERN). Pediatrics. 2017;139:e20162887.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Journal Article > Study

Tell me how pleased you are with your workplace, and I will tell you how often you wash your hands.

Sholomovich L, Magnezi R. Am J Infect Control. 2017;45:677-681.

Health care–associated infections (HAIs) are a significant source of preventable harm to patients. Although prior research has shown that clean hands are essential for reducing HAIs, health care institutions continue to struggle with hand hygiene compliance. In this study, investigators surveyed 400 nurses at a pediatric hospital and found a positive correlation between psychological safety and belief in personal responsibility for preventing the spread of infection. The authors argue that improving the psychological safety of staff may augment the response to hand hygiene initiatives.

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

Finding diagnostic errors in children admitted to the PICU.

Davalos MC, Samuels K, Meyer AND, et al. Pediatr Crit Care Med. 2017;18:265-271.

Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.

Journal Article > Study

Rudeness and medical team performance.

Riskin A, Erez A, Foulk TA, et al. Pediatrics. 2017;139:e20162305.

Disruptive and rude behavior by clinicians can hinder teamwork and diminish patient safety. In this simulation study, neonatal intensive care unit teams were randomized to exposure to rude comments versus neutral comments, with two additional teams randomized to exposure to rudeness with either a cognitive bias mitigation intervention or a narrative intervention. Rudeness was associated with worse performance, but training health care professionals to avoid cognitive distraction ameliorated the negative effect of rudeness.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Journal Article > Study

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

Journal Article > Study

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

Tawfik DS, Sexton JB, Kan P, et al. J Perinatol. 2017;37:315-320.

Burnout has been linked to work dissatisfaction and increased rates of adverse events. This retrospective study found that burnout was prevalent among health care workers in the neonatal intensive care unit setting. In high-volume centers, burnout was correlated with higher rates of health care–associated infections. These results demonstrate the association between burnout and care quality.

Journal Article > Study

National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.

Gaither JR, Leventhal JM, Ryan SA, Camenga DR. JAMA Pediatr. 2016;170:1195-1201.

Despite recent policy efforts, opioid overdose remains a serious patient safety issue in the United States. Researchers found that between 1997 and 2012, hospitalizations for opioid poisoning among pediatric patients nearly doubled. Children are particularly vulnerable to risks associated with opioids, and the authors suggest that pediatric-specific recommendations for opioid prescribing are needed.

Journal Article > Study

Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.

Rashed AN, Tomlin S, Aguado V, Forbes B, Whittlesea C. Int J Clin Pharm. 2016;38:1069-1074.

Pediatric medication errors are common. In this study, researchers observed 153 nurse preparations of morphine infusions for pediatric patients and found significant variation in technique, which led to many patients receiving doses higher or lower than what was initially ordered.

Back to Top