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Search results for "Health Care Executives and Administrators"

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Web Resource > Course Material/Curriculum

TeamSTEPPS 2.0 Core Curriculum.

Rockville, MD: Agency for Healthcare Research and Quality; September 2015.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

Book/Report

Patient Safety Culture: Theory, Methods and Application.

Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.

This publication covers patient safety culture including its background in high-risk industries, key concepts involved such as behavior change, measurement and assessment processes, and lessons learned from application and practice.

Perspectives on Safety > Interview

In Conversation With… Sidney Dekker, MA, MSc, PhD

Update on Just Culture, September 2013

Professor Sidney Dekker has done revolutionary work on human error and safety and written several bestselling books on system failure and just culture.

Newspaper/Magazine Article

The silent treatment: 'just be quiet about it'.

Smerd J. Workforce Management. November 19, 2007;1, 16-20.

This article describes the "culture of fear" in health care settings that discourages open communication about medical errors and other issues affecting the safety of care.

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.

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005

A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005

In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...

Journal Article > Study

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

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 > Review

Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration.

Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Appl Clin Inform. 2017;8:12-34.

The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.

Journal Article > Commentary

You can't blame the wreck on the train.

Potts JR III. Am J Surg. 2016 Dec 21; [Epub ahead of print].

Insufficient supervision can limit resident education, which may increase risks to patient safety. This commentary outlines factors that reduce the effectiveness of general surgery resident supervision and provides suggestions to augment supervision, including developing policies that outline when resident supervision is required and educating hospital executives about the need for appropriate oversight of care delivered by trainees.

Journal Article > Study

Applying the high reliability health care maturity model to assess hospital performance: a VA case study.

Sullivan JL, Rivard PE, Shin MH, Rosen AK. Jt Comm J Qual Patient Saf. 2016;42:389-411.

High reliability organizations operate in high-hazard domains with consistently safe conditions. Through individual interviews, investigators determined that staff perceptions of patient safety largely matched their conceptual model of a high reliability health care organization and found two additional characteristics: teamwork and systems approaches to improvement. The authors suggest their model of high reliability organizations can be used to assess organizational reliability.

Journal Article > Study

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.

Segall N, Bonifacio AS, Barbeito A, et al. Jt Comm J Qual Patient Saf. 2016;42:400-414.

Human factors engineering aims to optimize performance by examining the relationship between individuals and the system within which they work. This field of study has long been used to improve the safety of industries like manufacturing and aviation, and it has more recently been applied to health care. This study used human factors approaches to conduct observations, surveys, interviews, and focus groups about handoffs, specifically for postsurgical patients transferred from the operating room to the intensive care unit. The investigators identified flaws in handoff practices; then they designed a standardized handoff process to address these vulnerabilities. The redesigned handoff did not take more time than prior handoffs but did demonstrate better participant satisfaction. The authors suggest that their human factors-based improvement approach could be applied to other patient safety processes. A past PSNet interview discussed the application of human factors to health care.

Journal Article > Review

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-366.

Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.

Journal Article > Study

A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions.

Mathew R, Gundy S, Ulic D, Haider S, Wasi P. Acad Med. 2016;91:1284-1292.

Although duty hour restrictions were enacted to improve patient safety, evidence regarding their impact has been mixed. This focus group study examined resident perceptions of quality of life and patient safety before and after implementation of a reduced duty hours model. Participants reported less fatigue but also expressed concern about the greater number of handoffs, echoing the ongoing duty-hours debate discussed in a recent PSNet perspective.

Journal Article > Commentary

Challenges in patient safety improvement research in the era of electronic health records.

Russo E, Sittig DF, Murphy DR, Singh H. Healthc (Amst). 2016;4:285-290.

Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.

Journal Article > Study

Relationship between operating room teamwork, contextual factors, and safety checklist performance.

Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.

Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.

Journal Article > Study

Cultural transformation after implementation of crew resource management: is it really possible?

Hefner JL, Hilligoss B, Knupp A, et al. Am J Med Qual. 2017;32:384-390.

Crew resource management (CRM), a type of team training, is a prime example of an aviation strategy often applied to patient safety. Despite many calls to disseminate CRM throughout health care, data on its effectiveness in improving safety is lacking. This multi-site study examined safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture, before and after implementation of CRM in eight departments, across three hospitals. After the training, investigators found a significant, consistent improvement across multiple domains of safety culture, particularly in the areas of teamwork and communication. They propose more widespread implementation of CRM as a strategy to enhance safety culture. A past PSNet interview described the application of CRM to health care.

Journal Article > Commentary

Using computerized prescriber order entry to limit overrides from automated dispensing cabinets.

Drake E, Srinivas P, Trujillo T. Am J Health Syst Pharm. 2016;73:1033-1035.

Automated dispensing cabinets have been adopted in hospitals to enhance medication safety. These drug dispensing systems enable override functions so that nurses can access medications without pharmacist verification to ensure timeliness, but this workaround requires a reliable process to reduce the potential for errors. This commentary discusses how one hospital designed an oversight process using computerized provider order entry to increase the safety of this practice.

Journal Article > Review

Healthcare staff wellbeing, burnout, and patient safety: a systematic review.

Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. PLoS One. 2016;11:e0159015.

Many experts have raised concerns that increasing clinician burnout will hinder patient safety. This systematic review found that poor well-being and burnout in health care workers were associated with worse patient safety outcomes. The authors suggest that improving well-being at work for health care staff should be a part of patient safety efforts.

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