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Search results for "Hospitals"

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Journal Article > Commentary

The development of the National Reporting and Learning System in England and Wales, 2001-2005.

Williams SK, Osborn SS. Med J Aust. 2006;184:S65-S68.

The authors describe lessons learned from a 4-year effort to develop and implement a national reporting system in the United Kingdom.

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

Journal Article > Study

The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program.

Burke RE, Schnipper JL, Williams MV, et al. Med Care. 2017;55:285-290.

This retrospective cohort study demonstrated that a readmission risk score could prospectively identify patients at risk for readmissions for the four target conditions for nonpayment: acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure. These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions to prevent readmission.

Journal Article > Study

Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

Wagner C, Merten H, Zwaan L, Lubberding S, Timmermans D, Smits M. BMJ Open. 2016;6:e011277.

Incident reporting systems and root cause analyses remain the main mechanisms by which adverse events are identified and reviewed. This study sought to determine whether more localized, unit-based incident reporting systems might provide better insight into how patient safety incidents vary across hospital units and services than hospital or national level reporting systems. While similar safety issues and root causes were identified across all units and services, medication safety issues were more common on internal medicine and surgical units. On the other hand, collaboration issues were more frequent in emergency medicine units. These findings suggest that localized safety reporting systems might provide information that could promote improvement efforts.

Journal Article > Commentary

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

Robinson SN, Neyens DM, Diller T. Am J Med Qual. 2017;32:285-291.

There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.

Journal Article > Commentary

Chemotherapy errors: a call for a standardized approach to measurement and reporting.

Lennes IT, Bohlen N, Park ER, Mort E, Burke D, Ryan DP. J Oncol Pract. 2016;12:e495-e501.

Chemotherapy is a complicated process, and it is vulnerable to error due to factors that can affect the various steps involved. This commentary describes how one multidisciplinary cancer center designed and applied a taxonomy to report and monitor chemotherapy errors. The authors summarize the results of the work and provide suggestions for organizations that seek to develop similar tracking and analysis methods.

Journal Article > Study

The effects of power, leadership and psychological safety on resident event reporting.

Appelbaum NP, Dow A, Mazmanian PE, Jundt DK, Appelbaum EN. Med Educ. 2016;50:343-350.

The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review (CLER) program encourages resident participation in patient safety programs, including reporting errors and near misses. This survey found that perceived psychological safety was a critical predictor of residents' willingness to report events, highlighting the importance of an overall culture of safety in encouraging error reporting. A recent PSNet interview discussed the CLER program and its impact on medical education.

Journal Article > Commentary

The bare minimum: the reality of global anaesthesia and patient safety.

McQueen K, Coonan T, Ottaway A, et al. World J Surg. 2015;39:2153-2160.

Low- and middle-income countries face unique barriers to safe care delivery. This commentary reviews existing practice guidelines for providing safe anesthesia during surgery and recommends a baseline expectation of achievable patient safety in resource-challenged environments.

Journal Article > Study

Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration.

Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. J Am Geriatr Soc. 2015;63:1601-1607.

This health system performance study ranked sites within the Veterans Affairs health system using two measures of potentially inappropriate prescribing in older veterans. Researchers found that sites ranked similarly when they used new potentially inappropriate medications to measure performance compared to when they used existing potentially inappropriate medications as the measure. These results suggest that measuring new potentially inappropriate prescriptions is a feasible strategy worthy of further study.

Journal Article > Commentary

Organisational reporting and learning systems: innovating inside and outside of the box.

Sujan M, Furniss D. Clin Risk. 2015;21:7-12.

Incident reporting systems are a popular method for hospitals to detect patient safety hazards, but little progress has been made in utilizing information from these systems to reduce risks. This commentary describes the experiences of two projects aimed at learning from error reports, an internal organizational approach operated by local teams and an external social media mechanism hosted on a public Web site.

Journal Article > Study

Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.

Zaheer S, Ginsburg L, Chuang YT, Grace SL. Health Care Manage Rev. 2015;40:13-23.

This survey found that the ease with which errors can be reported is an important driver of frontline staff perception of safety culture at the unit level. A frequent criticism of many voluntary error reporting systems is that they are cumbersome and not straightforward to use.

Journal Article > Study

Adverse events in patients with return emergency department visits.

Calder L, Pozgay A, Riff S, et al. BMJ Qual Saf. 2015;24:142-148.

This observational study examined all return emergency department visits within 7 days of an initial visit to determine if the second visit was caused by an adverse event. An adverse event was present in 12% of return visits that occurred within 72 hours of the initial visit. The authors suggest that this utilization pattern may be a promising trigger tool to identify adverse events.

Journal Article > Study

Mobile physician reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident on call activities.

Nabors C, Peterson SJ, Aronow WS, et al. J Patient Saf. 2014;10:211-217.

Engaging physicians in voluntary safety reporting has generally been challenging. In this study, internal medicine residents reported many more clinically significant events following the introduction of an easy-to-use mobile platform that combined event reporting with patient signout.

Journal Article > Study

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.

Provenzano A, Rohan S, Trevejo E, Burdick E, Lipsitz S, Kachalia A. BMJ Qual Saf. 2015;24:31-37.

Early efforts to characterize patient safety included the review of individual cases of patient deaths; mortality reviews remain a core aspect of hospital safety efforts. This study describes the implementation of an electronic tool which directly queries clinicians about specific cases of inpatient deaths. The authors determined that the tool was feasible to implement, and clinicians reported delays in accessing or responding to tests, communication barriers, and health care–associated infections as contributors to preventable inpatient mortality. When comparing clinician responses to administrative data, there was little agreement about the presence of complications, with neither source consistently identifying more complications. This work suggests that directly engaging with clinicians about inpatient mortality yields useful patient safety data beyond what chart review can provide and underscores the need to improve existing clinical documentation to support safety efforts.

Journal Article > Study

Sociocultural factors influencing incident reporting among physicians and nurses: understanding frames underlying self- and peer-reporting practices.

Hewitt T, Chreim S, Forster A. J Patient Saf. 2014 Aug 26; [Epub ahead of print].

It has been well documented that physicians and nurses utilize voluntary error reporting systems in markedly different ways, with physicians much less likely to report errors. This qualitative study explores the sociocultural beliefs of both groups that influence their likelihood of voluntarily reporting errors.

Journal Article > Study

Older folks in hospitals: the contributing factors and recommendations for incident prevention.

Mansah M, Griffiths R, Fernandez R, Chang E, Thuy Tran D. J Patient Saf. 2014;10:146-153.

This retrospective review of incident reports at a tertiary care hospital revealed that errors related to falls, medication management, and clinical care were the most common adverse events among patients aged 65 years and older. This finding mirrors prior studies suggesting that older adults experience high rates of harm while receiving medical treatment.

Journal Article > Study

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.

Hospital incident reporting systems are ubiquitous, but many events remain unreported. This pre-post study sought to determine the impact of a reengineered medication error reporting approach. Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process in which clinical managers perform the first review of the report. The intervention led to increased error reporting, with the majority of errors being near-misses. This finding suggests that under-reporting of medication errors via standard incident reporting mechanisms can be addressed using human factors engineering approaches, which apply to and enhance both the error reporting tool and clinicians' workflow. A past AHRQ WebM&M perspective discusses how human factors engineering can be used to uncover problems with device design and work processes.

Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.

Journal Article > Study

Trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns.

Schwappach DLB, Gehring K. BMC Health Serv Res. 2014;14:303.

Although doctors and nurses in an oncology unit all agreed on the importance of speaking up in unsafe situations, they described various barriers to actually doing so, including the potential to damage relationships and concern about the accuracy of their own assessment of the situation.

Journal Article > Commentary

Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong.

Jones A, Kelly D. BMJ Qual Saf. 2014;23:709-713.

This commentary explores the differences between individuals failing to raise concerns and organizations disregarding problems that have been reported. Several organizational failures in the National Health Service provide context for this comparison and illustrate the need to build systems that reliably record and respond to shortcomings raised by staff.

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