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Search results for "Health Care Executives and Administrators"

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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 > Commentary

Why July matters.

Petrilli CM, Del Valle J, Chopra V. Acad Med. 2016;91:910–912.

Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient mortality increases during the July transition—truly exists. This commentary describes how leadership, supervision, mentor–learner pairings, and communication enhancement can help to reduce risks in this period. The authors suggest that applying strategies from aviation to augment teamwork between interns and residents could be an effective improvement strategy.

Journal Article > Commentary

Toward a safer health care system: the critical need to improve measurement.

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Jha A, Pronovost PJ. JAMA. 2016;315:1831-1832.

In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.

Journal Article > Review

From tokenism to empowerment: progressing patient and public involvement in healthcare improvement.

Ocloo J, Matthews R. BMJ Qual Saf. 2016;25:626-632.

Patient participation is considered a key component of patient safety initiatives. This review examined patient engagement programs and policies and determined that the current methods do not result in true public involvement in safety improvement. The authors suggest broader strategies are needed to engage the public in co-designing a safer health care system.

Journal Article > Study

Can medical record reviewers reliably identify errors and adverse events in the ED?

Klasco RS, Wolfe RE, Lee T, et al. Am J Emerg Med. 2016;34:1043-1048.

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.

Journal Article > Commentary

Patient safety and the problem of many hands.

Dixon-Woods M, Pronovost PJ. BMJ Qual Saf. 2016;25:485-488.

Although individual and organizational accountability are important elements of safety, they can also hinder system-wide improvement. This commentary discusses challenges to coordinating actions and accountability among and throughout the various components in health care, such as hospitals, governmental agencies, insurers, and accreditors. To achieve improvements, the authors propose that health care needs to establish a collective responsibility to develop collaborative solutions that balance global standards with local interventions.

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 > Commentary

Speak up! Addressing the paradox plaguing patient-centered care.

Mazor KM, Smith KM, Fisher KA, Gallagher TH. Ann Intern Med. 2016;164:618-619.

Although patients have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions often have no system in place to ensure such concerns are promptly addressed. This commentary explores the disconnect between intention and action and suggests steps to be taken so that health systems can achieve benefits of patient engagement initiatives.

Journal Article > Study

A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.

Bock M, Doz P, Fanolla A, et al. JAMA Surg. 2016;151:639-644.

The surgical safety checklist has generally been evaluated based on outcomes that occur within 30 days of the primary operation. For instance, the initial studies by the World Health Organization showed remarkable improvements in mortality and morbidity within 30 days, while a more recent retrospective study following mandated implementation of the checklist throughout Ontario failed to show any enhanced safety outcomes over this same interval. This current study evaluated the introduction of a surgical safety checklist at a single academic Italian hospital, measuring 90-day all-cause mortality, length of stay, and 30-day readmission rates, in addition to 30-day mortality rates. The study included approximately 10,000 patients undergoing noncardiac surgery, with about half in the preintervention and postintervention groups. Following checklist implementation, 90-day mortality significantly decreased, 30-day all-cause mortality was unchanged, and adjusted length of stay dropped from 10.4 to 9.6 days; no difference was found in readmission rates. A recent PSNet interview with Dr. Lucian Leape explored the conflicting findings of the efficacy of surgical safety checklists.

Journal Article > Study

Crew resource management training in the intensive care unit. A multisite controlled before-after study.

Kemper PF, de Bruijne M, van Dyck C, So RL, Tangkau P, Wagner C. BMJ Qual Saf. 2016;25:577-587.

This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.

Journal Article > Study

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.

François P, Prate F, Vidal-Trecan G, Quaranta JF, Labarere J, Sellier E. BMC Health Serv Res. 2016;16:35.

Morbidity and mortality (M&M) conferences are a classic patient safety education and feedback strategy. This study found that elements of M&M conferences, including thorough investigation of failures, predicted whether an improvement initiative was implemented. This work suggests that M&M conferences can be optimally designed to foster subsequent improvement efforts.

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 > Review

Managing and mitigating conflict in healthcare teams: an integrative review.

Almost J, Wolff AC, Stewart-Pyne A, McCormick LG, Strachan D, D'Souza C. J Adv Nurs. 2016;72:1490-1505.

This narrative review found that factors associated with personality, attitudes, role ambiguity, and work environment all contribute to interpersonal conflict in health care settings. The authors describe possible interventions to reduce conflict, which should in turn improve patient safety.

Journal Article > Study

Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.

Simon M, Maben J, Murrells T, Griffiths P. J Health Serv Res Policy. 2016;21:147-155.

This study expands on analyses and conclusions from published findings exploring the effects of moving to a new hospital with 100% single room accommodations. The researchers used nonequivalent controls by comparing results to a hospital that had not changed buildings but planned to do so (steady state control) and a hospital that moved to a new building with fewer than 50% single rooms (new build control). Falls, pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after the move to single rooms. However, there was also a significant change in the case mix on this ward following the move, which may have explained these changes in adverse events. On the acute assessment unit, falls and medication errors temporarily increased for the first 6 months but then returned to prior rates. The authors found neither clear evidence of benefit nor increased risk of harm attributable to moving to all single room accommodations.

Journal Article > Commentary

Rating the raters: the inconsistent quality of health care performance measurement.

Shahian DM, Normand ST, Friedberg MW, Hutter MM, Pronovost PJ. Ann Surg. 2016;264:36-38.

Public ratings of hospital quality and safety data may not always provide the best information for patients and clinicians. This commentary discusses problems with the existing set of patient safety metrics and suggests that measurement approaches need to be improved to enhance transparency and decision making.

Journal Article > Review

How safe is primary care? A systematic review.

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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

Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study.

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Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Ann Intern Med. 2016;164:1-9.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This cohort study examined treatment patterns for patients who had experienced a nonfatal opioid overdose. More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17% of those patients experienced another overdose event. An accompanying editorial notes the lack of systems to ensure clinicians' awareness of patients' opioid overdoses and recommends enhancing training and support so that clinicians are prepared to treat chronic pain and addiction. New approaches are urgently needed given this crisis in medication safety. A previous WebM&M commentary discussed the challenges of prescribing safely for chronic opioid users.

Audiovisual > Audiovisual Presentation

2015 Rosenthal Symposium: Protecting Patients: Advances and Future Directions in Patient Safety.

National Academy of Medicine. December 10, 2015; National Academy of Sciences Building, Washington, DC.

In recognition of the 15th anniversaries since To Err Is Human and Crossing the Quality Chasm were published, this symposium discussed accomplishments and persisting challenges in the fields of patient safety and quality improvement since those reports were released. The session featured Dr. Donald Berwick, Dr. Lucian Leape, and Carolyn Clancy as speakers.

Journal Article > Study

Association of safety culture with surgical site infection outcomes.

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Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.

Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.

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