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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

An observational study to evaluate the usability and intent to adopt an artificial intelligence–powered medication reconciliation tool.

Long J, Yuan MJ, Poonawala R. Interact J Med Res. 2016;5:e14.

This study describes the development of a tablet-based program that includes artificial intelligence elements for guiding patients through medication reconciliation. The researchers observed 10 patients using the tool and collected survey feedback on its usability and value from a small number of physicians, nurses, and patients.

Book/Report

The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events.

  • Classic

Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership; 2015.

Delayed diagnosis of infectious disease can negatively affect patients, care teams, and public health. Reviewing insights from a panel analysis of the well-known incident involving delayed diagnosis of Ebola virus, this report highlights the need to improve information transfer and emergency department safety culture to enhance diagnostic and infection prevention processes.

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.

Book/Report

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309293099.

Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient settings, as their care involves exposure to high-risk medications and requires closely coordinated care. Seen in that light, this Institute of Medicine report, which bluntly concludes that the current system of cancer care is untenable, is particularly concerning. The report highlights numerous deficiencies in the current system, such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure to incorporate patient preferences into advanced care planning. To reshape how cancer care is delivered, the report recommends leveraging information technology to augment care coordination and real-time analysis of treatment data, better end-of-life planning, and improving communication with patients and families around prognosis and the risks and benefits of treatments. Multiple AHRQ WebM&M commentaries discuss safety issues in oncology patients, including a case of a chemotherapy medication error detected by the patient himself and a near-fatal error ascribed in part to poorly coordinated care.

Journal Article > Commentary

Leading a highly visible hospital through a serious reportable event.

Erickson JI. J Nurs Adm. 2012;42:131-133.

This commentary describes how culture, transparency, and resilience helped a chief nurse executive manage the consequences of a high-profile clinical alarm failure.

Journal Article > Commentary

Aging gracefully? Patient safety advocates call for ongoing skills assessments for older physicians.

McKenna M. Ann Emerg Med. 2011;58:A15-A17.

This commentary suggests that emergency medicine adopt a mandatory retirement age and conduct ongoing skills assessment to ensure aging physicians can practice safely.

Newspaper/Magazine Article

Medical error led to death of patient, 77.

Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.

This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2017.

Harvard Medical School. October 16-17, 2017; Sheraton Boston Hotel, Boston, MA.

This workshop offers insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. This conference has expanded its scope beyond clinicians and patient safety officers to provide educational resources for pharmacists and nurses. Keynote speakers include James Conway and Dr. Thomas H. Lee.

Meeting/Conference > Oregon Meeting/Conference

Speak Up for Patient Safety: Communicating Before, During and After an Adverse Event.

Oregon Patient Safety Commission. August 11, 2017; OMEF Event Center, Portland, OR.

Effective communication among clinical teams and with patients and families is a key component of safe patient care. This workshop will discuss strategies to enhance communication among staff and patients, including concepts from TeamSTEPPS and how to foster a culture that promotes identifying areas for improvement and remaining transparent during an incident.

Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

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

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Newspaper/Magazine Article

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

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