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Approach to Improving Safety
Safety Target
- Device-related Complications 1
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- Identification Errors 2
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- Surgical Complications 9
Search results for "Hospitals"
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- Public Reporting
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22 California hospitals earn top status for outstanding patient safety & health care quality.
San Francisco, CA: The Leapfrog Group; May 2, 2006.
This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.
Journal Article > Study
Associations between hospital characteristics, measure reporting, and the Centers for Medicare & Medicaid Services overall hospital quality star ratings.
DeLancey JO, Softcheck J, Chung JW, Barnard C, Dahlke AR, Bilimoria KY. JAMA. 2017;317:2015-2017.
The Centers for Medicare and Medicaid Services (CMS) recently implemented the star rating system for hospitals as an overall measure of quality and safety. Although studies have found a correlation between the star ratings and clinical outcomes, this study found that high star ratings were more likely to be given to specialty or critical access hospitals. These hospitals are exempt from some of the CMS quality measure reporting requirements, and thus they did not report the same data as lower-rated hospitals. Other studies have also called into question the methodology behind the star rating system.
Newspaper/Magazine Article
Secret data on hospital inspections may soon become public.
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.
Newspaper/Magazine Article
Many well-known hospitals fail to score high in Medicare rankings.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
Journal Article > Commentary
Patient safety: disclosure of medical errors and risk mitigation.
Moffatt-Bruce SD, Ferdinand FD, Fann JI. Ann Thorac Surg. 2016;102:358-362.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.
Newsletter/Journal
Innovations to improve patient safety.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
Newspaper/Magazine Article
Rating hospitals by the stars: the feds' latest plan to measure quality is the most controversial.
Rau J. Washington Post. May 17, 2016.
Collecting data to meet quality measurement requirements adds to resource burden for many health care organizations, and there is controversy around the benefits of such rating systems for both patients and clinicians. This news article discusses problems with the Centers for Medicare and Medicaid Services rating mechanism, Hospital Compare.
Audiovisual
California hospitals make hundreds of errors every year, public is unaware.
Stock S, Putnam J, Carroll J, Pham S. NBC Bay Area. November 19, 2014.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.
Audiovisual
Thousands of doctors practicing despite errors, misconduct.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
Book/Report
Improving America's Hospitals—The Joint Commission's Annual Report on Quality and Safety.
- Classic
Oakbrook Terrace, IL: Joint Commission.
The Joint Commission's annual report summarizes hospital performance across a broad range of metrics that represent evidence-based standards for high-quality care. These accountability measures have been shown to be directly linked to patient outcomes. Since the report's first publication in 2007, data demonstrates that hospitals have measurably improved quality of care for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Newspaper/Magazine Article
Revealing their medical errors: why three doctors went public.
O'Reilly KB. American Medical News. August 15, 2011.
This news article reports on health care providers who have publicly revealed direct involvement in cases of medical errors, with a goal of encouraging open disclosure, encouraging safety checks, and improving patient safety.
Book/Report
Consumers' Priorities for Hospital Quality Improvement and Implications for Public Reporting.
Ginsburg M, Glasmire K. Oakland, CA: California HealthCare Foundation; April 2011.
Examining consumers' opinions on health care quality and safety, this report offers recommendations for hospitals to prioritize improvement efforts.
Newspaper/Magazine Article
Driving out errors.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Newspaper/Magazine Article
First do no harm.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Newspaper/Magazine Article
A pinpoint beam strays invisibly, harming instead of healing.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Newspaper/Magazine Article
Dennis Quaid's Quest.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.
Newspaper/Magazine Article
Do no harm: hospital care in Las Vegas.
Allen M, Richards A. Las Vegas Sun. June 27, 2010.
This news series reports on an investigation that included hospital record review and interviews with stakeholders to explore the quality and safety of health care in Las Vegas.
Journal Article > Study
Adherence to Surgical Care Improvement Project measures and the association with postoperative infections.
- Classic
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. JAMA. 2010;303:2479-2485.
Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.
Newspaper/Magazine Article
Transparency and public reporting are essential for a safe health care system.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
Book/Report
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
America's hospitals continued to improve the quality of care they provide for myocardial infarction, congestive heart failure, pneumonia, and surgical care, according to the newest report from The Joint Commission. Compared to the prior report published in 2007, hospitals increased their provision of evidence-based treatments across all four disease processes. In particular, significant improvements were achieved in use of measures to prevent surgical site infections. While the prior report provided data on adherence to the National Patient Safety Goals, these measures were not discussed in the current report.
