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Search results for "Hospitals"

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Journal Article > Commentary

Concepts for the development of a customizable checklist for use by patients.

Fernando RJ, Shapiro FE, Rosenberg NM, Bader AM, Urman RD. J Patient Saf. 2015 Jun 10; [Epub ahead of print].

Checklists have been highlighted as useful tools for nurses and physicians to improve communication and reduce care omissions. This commentary describes the development of a customizable checklist template designed to enable patients to engage in their care and safety.

Book/Report

The Patient Survival Handbook.

Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.

Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.

Journal Article > Study

Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites.

Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Acad Med. 2017 Mar 28; [Epub ahead of print].

Contextual errors can occur when health care providers fail to consider a patient's individual context, such as limited literacy, when making a treatment plan. This qualitative study of clinicians identified 12 types of contextual errors that can impede patient self-management and lead to harm. The authors advocate a "contextual differential" to consider these potential errors.

Book/Report

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.

Wright J, Lawton R, O'Hara J, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.

Journal Article > Study

Patients' identification and reporting of unsafe events at six hospitals in Japan.

Hasegawa T, Fujita S, Seto K, Kitazawa T, Matsumoto K. Jt Comm J Qual Patient Saf. 2011;37:502-508.

This Japanese survey found that that only 17% of adverse events reported by patients were captured by standard adverse event reporting systems.

Journal Article > Study

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers.

Öhrn A, Elfström J, Liedgren C, Rutberg H. Jt Comm J Qual Patient Saf. 2011;37:495-501.

Hospitals are being encouraged to engage patients in safety programs, in part because prior studies have shown that patients themselves can be a unique source of information about adverse events. In Sweden, clinicians are required to report cases of serious adverse events, and patients can obtain compensation for such events through a no-fault malpractice insurance system. However, this study found that more than 80% of cases where patients were compensated for severe injuries were not reported by practitioners, including many cases of health care–associated infections and diagnostic errors. The related editorial calls for hospitals to redouble their efforts to promote patient participation in reporting and addressing patient safety problems.

Journal Article > Study

Beyond service quality: the mediating role of patient safety perceptions in the patient experience–satisfaction relationship.

Rathert C, May DR, Williams ES. Health Care Manage Rev. 2011;36:359-368.

While patients are being encouraged to take a more active role in patient safety, concerns persist that patient satisfaction may be more influenced by service quality rather than safety issues. However, this survey of hospitalized patients found that both perceptions of safety and service quality influenced overall patient satisfaction.

Cases & Commentaries

Patient Safety and Adherence to Self-Administered Medications

  • Web M&M

Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD; July 2011

A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.

Cases & Commentaries

Watch the Warfarin!

  • Spotlight Case
  • Web M&M

Margaret Fang, MD, MPH; Raman Khanna, MD, MAS; July 2011

Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.

Newspaper/Magazine Article

Medical misdiagnoses can have fatal consequences.

Olsen D. State Journal-Register. June 26, 2011.

This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.

Newspaper/Magazine Article

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

ISMP Medication Safety Alert! Acute Care Edition. June 16, 2011;16:1-3.

This newsletter piece provides recommendations to strengthen parental involvement during a child's hospitalization.

Newspaper/Magazine Article

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.

Journal Article > Study

Can we rely on patients' reports of adverse events?

  • Classic

Zhu J, Stuver SO, Epstein AM, Schneider EC, Weissman JS, Weingart SN. Med Care. 2011;49:948-955.

Traditional methods of error detection have relied mainly on provider input or administrative data, without emphasizing the role of the patient in safety. This study of more than 2000 patients recently discharged from Massachusetts hospitals found that patients could identify unique adverse effects of hospitalization that may not have been identified by other methods. Importantly, physician reviewers agreed that the patient-reported events constituted a true clinical adverse event in more than 70% of cases. This finding corroborates prior research showing that patient-reported adverse events provide an important complementary perspective in assessing organizational safety problems.

Journal Article > Commentary

Patient-assisted incident reporting: including the patient in patient safety.

Millman EA, Pronovost PJ, Makary MA, Wu AW. J Patient Saf. 2011;7:106-108.

This commentary suggests that patient-assisted incident reporting following an adverse event can reveal contributing factors the care team may have missed.

Journal Article > Study

Putting the 'patient' in patient safety: a qualitative study of consumer experiences.

Rathert C, Brandt J, Williams ES. Health Expect. 2012;15:327-336.

This survey identified communication problems as a major patient safety concern for hospitalized patients.

Newspaper/Magazine Article

Staying safe during a hospital stay.

Graham J. Los Angeles Times. May 11, 2011.

This newspaper article reports on common errors that may occur during hospitalization and offers tips for patients to participate in their safety.

Book/Report

Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

Farbstein K. Rockville, MD: Access Intelligence, LLC; 2011. ISBN: 9781885461452.

This book explores patient-centered care and provides strategies to help patients actively participate in their care.

Audiovisual

Obama Administration introduces plan to reduce preventable medical errors.

PBS News Hour. April 12, 2011.

This television news interview discusses results of a recent analysis of patient safety improvement efforts, describes the Partnership for Patients program, and offers tips to involve patients in safety.

Journal Article > Study

Acute care patients discuss the patient role in patient safety.

Rathert C, Huddleston N, Pak Y. Health Care Manage Rev. 2011;36:134-144.

This qualitative study used surveys of recently discharged inpatients to explore their perceptions of the patient's role in safety.

Journal Article > Study

Hospitalized patients' participation and its impact on quality of care and patient safety.

Weingart SN, Zhu J, Chiappetta L, et al. Int J Qual Health Care. 2011;23:269-277.

Hospitalized patients who reported a higher level of participation in their own care—for example, a greater understanding of their diagnoses—had a lower incidence of adverse events during hospitalization.

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