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Search results for "Hospitals"

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Book/Report

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.

Journal Article > Study

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Lee JS, Hu HM, Brummett CM, et al. JAMA. 2017;317:2013-2015.

The opioid crisis is one of the nation's most pressing patient safety problems. Concern has been raised that overprescribing of opioids may be an unintended consequence of efforts to improve patient satisfaction. However, this Michigan study found no relationship between postoperative opioid prescribing and patient satisfaction scores, indicating that efforts to reduce opioid prescribing may not adversely affect patient satisfaction.

Journal Article > Study

Dissecting Leapfrog: how well do Leapfrog Safe Practices Scores correlate with Hospital Compare ratings and penalties, and how much do they matter?

  • Classic

Smith SN, Reichert HA, Ameling JM, Meddings J. Med Care. 2017;55:606-614.

Hospital quality scores are publicly available, but the extent to which they reflect patient safety remains controversial. This study compared measures from the Leapfrog Group, which incorporates mandatory publicly reported data and voluntary self-reported data to give each hospital a letter grade, to mandatory publicly reported data on the Medicare's Hospital Compare website. Investigators found that most Leapfrog voluntary scores were close to perfect. For hospitals that did not report the voluntary component of the Leapfrog score, they modeled how the hospitals' overall letter grades would change if they had self-reported different performance levels. They found that self-reported data heavily influenced a hospital's letter grade. Leapfrog scores were not consistently associated with Hospital Compare data on hospital-acquired conditions like health care–associated infections, pressure ulcers, or falls. The authors suggest that Leapfrog data provides only a limited assessment of hospital performance.

Journal Article > Study

Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.

Smith SA, Yount N, Sorra J. BMC Health Serv Res. 2017;17:143.

Safety culture surveys of health care workers are often used to determine whether programs or interventions improve patient safety. This cross-sectional study examined the relationship between the AHRQ Hospital Survey on Patient Safety Culture score, a widely used metric for safety culture, and the Consumer Reports Hospital Safety Score, calculated using a combination of patient experience and adverse event data by an independent nonprofit organization. Among 164 hospitals in the United States, higher staff perceptions of safety culture were associated with better overall safety, as measured by a composite of reported harms and patient satisfaction. These results lend support to continued measurement and reporting of safety culture. A recent PSNet perspective provided insights for organizations seeking to achieve culture change.

Journal Article > Study

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

Gupta R, Moriates C, Harrison JD, et al. BMJ Qual Saf. 2017;26:475-483.

Health care institutions are increasingly focused on providing high-value care and preventing overuse. In this study, researchers developed a validated High-Value Care Culture Survey and found that administering the survey at two large academic medical centers provided health care leaders with an opportunity to target their improvement efforts.

Journal Article > Review

Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).

Classen DC, Munier W, Verzier N, et al. J Patient Saf. 2016 Oct 20; [Epub ahead of print].

The Medicare Patient Safety Monitoring System was developed to track adverse events nationally to support robust safety improvement. This review summarizes the history of the Medicare Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and utilization of the collected data.

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

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 > Study

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture.

Lee SH, Phan PH, Dorman T, Weaver SJ, Pronovost PJ. BMC Health Serv Res. 2016;16:254.

Timely and accurate handoff communication is a critical aspect of patient safety. This survey of hospital staff found that positive perceptions of handoff practices were associated with safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture. The authors suggest focusing on improving handoffs as a strategy to enhance safety culture.

Journal Article > Study

RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: a national cross-sectional study of acute-care hospitals.

Smeds-Alenius L, Tishelman C, Lindqvist R, Runesdotter S, McHugh MD. Int J Nurs Stud. 2016;61:117-124.

Nurses play a critical role in patient care through their constant presence at patients' bedsides, and they may have key insights into safety in their institutions. This study found that in hospitals where nurses rated quality of care as excellent, 30-day postsurgical mortality was better. The authors suggest that nursing perceptions of safety can inform targeting of improvement interventions.

Journal Article > Study

Comparing trainee and staff perceptions of patient safety culture.

Bump GM, Coots N, Liberi CA, et al. Acad Med. 2017;92:116-122.

Using the AHRQ Hospital Survey on Patient Safety Culture, this study compared how trainees and staff in 10 hospitals in an integrated health system perceived safety. Trainee and staff perceptions of safety culture differed, highlighting the challenges of coming to a common understanding of safety culture.

Journal Article > Study

Communication and shared understanding between parents and resident-physicians at night.

Khan A, Rogers JE, Forster CS, Furtak SL, Schuster MA, Landrigan CP. Hosp Pediatr. 2016;6:319-329.

This survey study identified significant communication gaps between parents of hospitalized children and the resident physicians caring for them overnight. Although both parents and physicians rated communication highly, there were differences in parent and physician understanding of the reason for admission, overall plan, and overnight plan, particularly for children with more complex illness. This demonstrates the gap between perceptions of communication and shared understanding.

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.

Book/Report

Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.

Cambridge, MA: CRICO Strategies; 2016.

Communication failures are known to contribute to medical errors. Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores selected specialties where such failures occur and discusses opportunities to improve information sharing among health care providers.

Journal Article > Study

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.

Health care organizations measure safety climate by surveying providers and staff at all levels. Investigators assessed safety culture and teamwork in 44 neonatal intensive care units using two different survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture. They found significant variation in safety and teamwork climate scales of both tools, indicating that the instruments should not be used interchangeably.

Journal Article > Study

Patient safety climate strength: a concept that requires more attention.

Ginsburg L, Gilin Oore D. BMJ Qual Saf. 2016;25:680-687.

Measuring safety culture is essential to patient safety improvement activities. Standardized safety culture surveys, including the Safety Attitudes Questionnaire and the AHRQ Surveys on Patient Safety Culture, are typically reported as numerical scores calculated by aggregating individual responses. This study analyzed safety culture surveys from an accreditation program in a novel manner. Investigators summarized the safety culture level (the averaged ratings of patient safety culture from respondents), culture strength (the consistency of safety ratings among all the members of a department), and culture shape (the distribution of numerical responses). Even among units with identical levels of safety culture, they found that the consistency and distribution of responses revealed different safety climates. One department had high degrees of agreement about safety culture while the other showed divergent perceptions. These two results have different implications for understanding safety culture. The authors advocate for examining agreement and distribution of safety culture survey results as well as mean scores in order to achieve a more comprehensive and actionable understanding of patient safety culture. A past PSNet interview discussed how to measure and change safety culture.

Book/Report

National Safety Standards for Invasive Procedures (NatSSIPs).

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.

Book/Report

2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process.

Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.

This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.

Journal Article > Commentary

The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.

Mellin-Olsen J, Staender S. Curr Opin Anaesthesiol. 2014;27:630-634.

Examining anesthesia safety in Europe following the recommendations outlined in the 2010 Helsinki Declaration, this review describes how checklists and an implementation toolkit contributed to progress and suggests areas requiring further work to achieve the document's goals.

Journal Article > Study

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.

Bisset GS III, Crowe J. Pediatr Radiol. 2014;44:552-557.

This study found that diagnostic errors in interpretation of pediatric musculoskeletal radiographs were relatively rare, occurring in 2.7% of cases. The majority of errors involved false negative readings (i.e., missed injuries).

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