Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Hospitals"

1 - 20 of 51 results
Download Selected Citations

Show: 20 | 50 | 100

Perspectives on Safety > Interview

In Conversation With… Paul H. O'Neill, MPA

Workplace Safety, January 2017

Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.

Perspectives on Safety > Perspective

Workplace Safety in Health Care

with commentary by Ross W. Simon and Elena G. Canacari, RN, Workplace Safety, January 2017

This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.

Journal Article > Commentary

Safety lessons from the NIH Clinical Center.

Gandhi TK. N Engl J Med. 2016;375:1705-1707.

System failures can remain undetected over time in large organizations. This perspective describes elements of a health care research environment that enabled lapses in safety, such as financial pressures and shifting priorities. The author calls for industry-wide learning from this example to ensure that patient safety remains a priority and that organizations invest and commit to an infrastructure that encourages safety.

Journal Article > Commentary

Measures to improve diagnostic safety in clinical practice.

Singh H, Graber ML, Hofer TP. J Patient Saf. 2016 Oct 20; [Epub ahead of print].

Efforts to reduce diagnostic errors are hindered by the lack of effective measures to track improvement. This commentary proposes a set of measures for consideration that have the potential to structure research and evaluation of diagnosis improvement initiatives.

Journal Article > Study

Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative.

Stone S, Lee HC, Sharek PJ. Jt Comm J Qual Patient Saf. 2016;42:309-319.

This implementation study examined factors that affect sustained improvement associated with an intervention to increase the rate of premature infants receiving breast milk. Investigators found that physician involvement and continuous education contributed to maintaining the intervention. Human factors efforts such as incorporating the intervention into daily workflow and providing feedback also supported this safety practice.

Book/Report

Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance.

McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.

Tools to collect and disseminate performance data can help improve care. This publication outlines how organizations can apply evidence-based strategies when designing voluntary reporting systems that engage clinicians and enable continuous improvement.

Journal Article > Commentary

Fifteen years after To Err Is Human: a success story to learn from.

Pronovost PJ, Cleeman JI, Wright D, Srinivasan A. BMJ Qual Saf. 2016;25:396-399.

When To Err Is Human was published, central line–associated bloodstream infections were considered an unavoidable patient safety problem. This commentary discusses how this mindset has changed over the past decade, citing the Keystone ICU project and other efforts that substantially decreased rates of this preventable hospital-acquired condition. The authors outline five elements that contributed to the reduction, including reliable and valid measurement processes, evidence-based care practices, and alignment around common goals and measures.

Journal Article > Commentary

Measuring and improving patient safety through health information technology: the Health IT Safety Framework.

Singh H, Sittig DF. BMJ Qual Saf. 2016;25:226-232.

Health information technology (IT) has promise for improving safety, but processes to measure and monitor its specific effect are lacking. Drawing from sociotechnical approaches and continuous quality improvement, this commentary outlines a framework for tracking improvements associated with the use of health IT. The framework focuses on three areas: concerns unique to technology, problems with use and misuse of health IT, and the ability of health IT systems to identify a failure and prevent it from affecting the patient.

Journal Article > Commentary

Reducing surgical errors: implementing a three-hinge approach to success.

Landers R. AORN J. 2015;101:657-665.

Errors in surgical care are often associated with human factors, interruptions, and staffing issues. This commentary describes a program to augment safety in ambulatory surgery centers, which includes a surgical checklist, change management, and teamwork.

Journal Article > Study

Implementing a standardized safe surgery program reduces serious reportable events.

Loftus T, Dahl D, OHare B, et al. J Am Coll Surg. 2015;220:12-17.e3.

Implementation of a safe surgery program resulted in a sustained decrease in serious reportable events within a health system over a 2-year period. The authors ascribe the success of the program to a planning process that involved human factors engineering approaches as well as an ongoing implementation and reinforcement program.

Book/Report

Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results.

Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277.

This publication provides information about the role of nurses in health care safety and explores how organizational dynamics, leadership, and hazard identification can affect the abilities of frontline nurses to deliver safe care. Helpful resources such as checklists, sample control plans, and review exercises are also included.

Journal Article > Study

Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study.

Simonsen BO, Daehlin GK, Johansson I, Farup PG. BMC Health Serv Res. 2014;14:580.

Nursing skill mix and training may be linked to patient outcomes, and one study showed lower inpatient mortality rates for a variety of surgical patients in hospitals with more highly educated nurses. In this study, practicing nurses had greater medication knowledge than graduating nursing students, but both groups had serious deficiencies, particularly in their ability to perform drug dose calculations correctly.

Journal Article > Study

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

McFadden KL, Stock GN, Gowen CR III. Health Care Manage Rev. 2015;40:24-34.

Analyzing survey and administrative data, this study links a transformational leadership style, in which health care leaders articulate a clear and shared vision for an organization, to a positive safety culture. The authors also found that a culture of safety was associated with robust continuous quality improvement. However, having improvement activities in place was correlated with higher rates of hospital-acquired conditions, according to data collected for the Hospital Compare Web site. This finding suggests that improvement initiatives themselves may not be sufficient to prevent adverse safety outcomes; for example, hospital-acquired conditions may in fact lead to interventions. The authors advocate for establishing both continuous quality improvement and a culture of safety to augment outcomes.

Journal Article > Study

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.

Pronovost PJ, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.

In 2010, The Joint Commission created accountability measures, evidence-based practices that produce positive impacts on patient outcomes. Each year, The Joint Commission recognizes Top Performers that provide more than 95% of their patients with recommended therapies for at least 3 accountability metrics. This article details Johns Hopkins Hospital's efforts to exceed the Top Performer award thresholds on multiple core measures. To realize this goal, the group developed a conceptual model that addresses the challenges accompanying quality and safety interventions. They also employed the Lean framework of define-measure-analyze-improve-control to help teams systematically create improvement plans. In addition, a monthly performance dashboard provided transparency and accountability. These efforts led to Johns Hopkins Hospital achieving a compliance goal of 96% or higher on 95% of the core measures in 2012. A previous AHRQ WebM&M interview with Dr. Peter Pronovost, the lead author of this paper, discussed the science of improving patient safety.

Journal Article > Review

Systematic review of the application of the plan-do-study-act method to improve quality in healthcare.

Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. BMJ Qual Saf. 2014;23:290-298.

This systematic review of the plan-do-study-act method of quality improvement showed that most studies do not report on the key methodological features of iterative cycles, tests of change, and data use in real time.

Journal Article > Study

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.

Taylor AM, Chuo J, Figueroa-Altmann A, DiTaranto S, Shaw KN. Jt Comm J Qual Patient Saf. 2013;39:396-403.

Leadership WalkRounds—derived from the business management approach of "management by walking around"—are being more widely used as a means of error detection and improving safety culture. This report from a children's hospital, in which structured walkrounds by nursing and physician leaders were implemented on six units, found that this approach increased staff engagement in safety efforts, identified hidden system flaws, and resulted in the successful implementation of multiple quality improvement projects. Although this study did not specifically measure the effect of walkrounds on safety climate, prior studies have found conflicting results, which might imply that different methods of performing walkrounds may influence their success.

Journal Article > Study

Long-term reduction in adverse drug events: an evidence-based improvement model.

Gazarian M, Graudins LV. Pediatrics. 2012;129:e1334-e1342.

A multifaceted, interdisciplinary, continuous quality improvement project successfully reduced adverse drug events at an Australian pediatric hospital. The improvement was driven by a nearly two-thirds reduction in the incidence of prescribing errors.

Journal Article > Study

Spreading a medication administration intervention organizationwide in six hospitals.

Kliger J, Singer S, Hoffman F, O'Neil E. Jt Comm J Qual Patient Saf. 2012;38:51-60.

While quality improvement projects can result in short-term, local success, ensuring the sustainability and spread of successful interventions can be extremely challenging. This follow-up study describes methods used to disseminate a successful project to reduce medication administration errors beyond the original pilot hospitals. The article details how stratiegies for communication, local adaptation, teamwork, and learning from failure were essential to implementing the intervention across a broad range of hospitals. This approach achieved sustained improvement in medication administration error rates in both the initial and subsequent groups of hospitals.

Journal Article > Commentary

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Harding AD. Am J Nurs. 2012;112:26-35. 

This commentary details how one hospital successfully increased use of smart pumps to improve medication safety.

Journal Article > Commentary

Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items.

Norton EK, Martin C, Micheli AJ. AORN J. 2012;1:109-121.

Describing an initiative to reduce count discrepancies in the operating room, this commentary found that it had sustainable positive impact.

Back to Top