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Search results for "Health Care Executives and Administrators"

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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

Can computers help doctors reduce diagnostic errors?

Shryock T. Med Econ. December 5, 2016.

Computerized decision support and advanced computing are being used to augment various processes in health care, such as medication ordering and diagnosis. This magazine article reports on the accuracy of these systems and the potential role of artificial intelligence in supporting diagnostic decision making.

Journal Article > Commentary

The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking.

Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. Acad Med. 2017;92:23-30.

Decision making is typically either intuitive or analytical. This commentary discusses the two types of decision making, how heuristics and cognitive biases affect diagnostic reasoning, and strategies to reduce diagnostic error.

Meeting/Conference > Massachusetts Meeting/Conference

Diagnostic Error in Medicine 10th International Conference.

Society to Improve Diagnosis in Medicine. October 8-10, 2017, Boston Marriott Newton, Newton MA.

This annual conference will focus on the theme, "Improving Diagnosis: It Takes a Team" to drive work in reducing diagnostic errors. Featured speakers include Dr. Donald Berwick, Professor Amy Edmondson and Dr David Mayer.

Meeting/Conference > Government Resource

AHRQ Research Summit on Improving Diagnosis in Health Care.

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

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

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review.

Cook DA, Teixeira MT, Heale BSE, Cimino JJ, Del Fiol G. J Am Med Inform Assoc. 2017;24:460-468.

Infobuttons, a form of clinical decision support, are small icons in the electronic health record that allow users to access online knowledge resources. This systematic review found some evidence that infobuttons may be helpful despite infrequent use. The authors advocate for further research to determine optimal design and implementation of infobuttons in electronic health records.

Journal Article > Study

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.

van Welie S, Wijma L, Beerden T, van Doormaal J, Taxis K. BMJ Open. 2016;6:e012286.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Journal Article > Study

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

Soban LM, Kim L, Yuan AH, Miltner RS. J Nurs Manag. 2016 Aug 4; [Epub ahead of print].

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

Journal Article > Review

Error disclosure in pathology and laboratory medicine: a review of the literature.

Perkins IU. AMA J Ethics. 2016;18:809-816.

Disclosure of errors to patients and families contributes to transparency in health care. This review explores barriers to disclosing diagnostic errors to patients in pathology and laboratory medicine and makes recommendations to address these challenges.

Journal Article > Commentary

Improving the communication between teams managing boarded patients on a surgical specialty ward.

Puvaneswaralingam S, Ross D. BMJ Qual Improv Rep. 2016;5.

Boarding patients as they transfer between wards can compromise patient safety. This commentary reviews how an otolaryngology ward implemented a simple cognitive aid to improve patient record review, information sharing, and team communication. The authors report the results of the project and how they intend to use plan-do-study-act cycles to refine the process.

Journal Article > Review

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

Green B, Parry D, Oeppen RS, Plint S, Dale T, Brennan PA. Oral Dis. 2016 Jul 22; [Epub ahead of print].

Situational awareness during critical incidents is a key component of teamwork. This review spotlights the importance of situational awareness in health care and provides information about how to assess and develop it in individual clinicians and among team members.

Journal Article > Study

Boosting medical diagnostics by pooling independent judgments.

Kurvers RHJM, Herzog SM, Hertwig R, et al. Proc Natl Acad Sci U S A. 2016;113:8777-8782.

Diagnostic error remains a significant source of preventable patient harm. Because bias on the part of health care providers can contribute to diagnostic errors, improving the medical decision-making process may serve as an error prevention strategy, possibly through the use of collective intelligence. This study sought to better understand the conditions under which collective intelligence might augment medical judgment. Using large data sets consisting of more than 140 doctors and 20,000 diagnoses, the investigators determined that when providers have similar individual diagnostic accuracy rates, pooling their judgments improves decision accuracy. However, if accuracy levels vary across providers, pooling independent judgment leads to worse diagnostic outcomes. The authors suggest that similar diagnostic accuracy should be a key condition when creating groups for the purpose of improving medical diagnosis. A previous WebM&M commentary discussed a case of diagnostic error.

Journal Article > Study

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

Yadav S, Kazanji N, Narayan KC, et al. J Am Med Inform Assoc. 2017;24:140-144.

Compared to paper charts, electronic health records offer safety benefits for physician documentation including better availability and legibility. However, electronic documentation introduces new concerns, such as copy-and-paste practices (which can perpetuate errors) and lack of diagnostic reasoning in electronic notes. This study compared physical exam documentation in initial physician progress notes before and after implementation of an electronic health record. Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts. Trainee physicians' documentation had fewer errors in both paper and electronic formats. The authors recommend that hospitals discourage copied notes and encourage accurate documentation at the time of the patient encounter. The importance of the physical examination itself was discussed in a PSNet interview with Dr. Abraham Verghese.

Journal Article > Study

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

Elmore JG, Tosteson AN, Pepe MS, et al. BMJ. 2016;353:i3069.

This study found that eliciting second opinions in pathology improved the accuracy of breast histopathology specimens. This work provides further evidence that diagnostic accuracy can be enhanced with second opinions. The authors suggest that implementing multiple clinician review may augment the diagnostic process.

Newspaper/Magazine Article

Tackling disrespectful, unprofessional provider behaviors.

ED Manag. June 2016;28:S1-S4.

Disrespectful conduct among health care providers can hinder safe care delivery. This article reviews insights from one hospital's unique program to encourage staff members to help identify individuals that could benefit from personalized coaching and training to manage their disruptive behaviors.

Book/Report

Antibiotic Stewardship in Acute Care: A Practical Playbook.

National Quality Partners. Washington, DC: National Quality Forum; 2016.

Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.

Cases & Commentaries

Situational Awareness and Patient Safety

  • Web M&M

Jeanne M. Farnan, MD, MHPE; April 2016

A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.

Journal Article > Study

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.

Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.

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