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Search results for "Health Care Executives and Administrators"

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Audiovisual > Audiovisual Presentation

The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety.

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

This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-­9 to ICD-­10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.

Tools/Toolkit > Measurement Tool/Indicator

High Reliability in Health Care.

Joint Commission Center for Transforming Healthcare.

Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability in health care. This website collects evidence and existing tools to help organizations work toward high reliability, including the ORO 2.0 assessment tool to enable hospital leaders evaluate their culture, leadership, and performance.

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.

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

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 > 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 > 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 > 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

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.

  • Classic

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.

Book/Report

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.

  • Classic

Boston, MA: National Patient Safety Foundation; 2015.

This report provides an objective assessment of the state of the safety field 15 years after the release of the Institute of Medicine's To Err Is Human. Acknowledging that progress has been slower than anticipated, the report makes eight recommendations for achieving total system safety, including creating a common set of safety metrics that reflect meaningful outcomes, establishing and sustaining a culture of safety, centralizing oversight of patient safety at the national level, improving the safety of information technology, and supporting patients, families, and the health care workforce. The report also highlights the need for greater investment in patient safety, particularly in the outpatient and long-term care areas. Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), discussed the evolving responsibilities of NPSF in a 2014 PSNet interview.

Book/Report

Saving Lives and Saving Money: Hospital-Acquired Conditions Update.

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Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.

The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.

Journal Article > Study

The effect of emergency department boarding on order completion.

Coil CJ, Flood JD, Belyeu BM, Young P, Kaji AH, Lewis RJ. Ann Emerg Med. 2016;67:730-736.e2.

When patients already designated as hospitalized remain as boarding in the emergency department, it poses a challenge for staff workflow as well as safety concerns for patients. This case-control study identified missed care and delayed care more frequently for boarded patients than other emergency department patients, adding to the criticism of this common practice.

Journal Article > Commentary

Improving diagnosis in health care—the next imperative for patient safety.

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Singh H, Graber ML. N Engl J Med. 2015;373:2493-2495.

The National Academy of Medicine report, Improving Diagnosis in Health Care, estimated that most US adults will experience one or more diagnostic errors in their lifetimes. Summarizing the goals from the report, this commentary details how the recommendations can lead to enhanced diagnostic safety and reduced patient harm. The authors also acknowledge potential challenges to implementing the systems and process changes described.

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