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Approach to Improving Safety
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Search results for "Hospitals"

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Journal Article > Commentary

The problem with checklists.

Catchpole K, Russ S. BMJ Qual Saf. 2015;24:545-549.

Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlighting the complexities around designing and implementing checklists to augment health care safety, this commentary relates the differences between medical and aviation checklists to underscore the need to consider sociocultural elements to ensure the success of this safety intervention.

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.

Journal Article > Study

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

Ely JW, Graber MA. Diagnosis. 2015;2:163–169.

In this randomized trial study, a diagnostic checklist for common symptoms in emergency department or urgent care clinic visits did not significantly reduce diagnostic errors compared to usual care, though a larger sample across more conditions may shed further light on the effectiveness of checklists in diagnosis.

Journal Article > Study

The effect of cognitive debiasing training among family medicine residents.

Smith BW, Slack MB. Diagnosis. 2015;2:117-121.

This educational intervention taught family medicine residents metacognition and debiasing strategies. Investigators found no change in attending–resident diagnostic agreement, recognition of cognitive bias risk, or attendings' perception of unrecognized cognitive bias. Participants were better able to form a plan to mitigate a cognitive bias. This work demonstrates some effectiveness and significant limitations of cognitive training as a way to augment diagnostic accuracy.

Web Resource > Multi-use Website

National Coalition for Alarm Management Safety.

Healthcare Technology Safety Institute and Association for the Advancement of Medical Instrumentation.

Alarm fatigue has been recognized as a contributor to serious errors in hospitals. This Web site provides a way for hospitals, industry representatives, regulators, and professional societies to compile resources and discuss strategies to reduce unnecessary alarms.

Book/Report

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

  • Classic

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

This report highlights how working conditions can affect health care workers and recommends seven strategies for organizations to improve workplace safety.

Book/Report

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

  • Classic

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.

Journal Article > Study

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety.

Brand C, Ibrahim J, Bain C, Jones C, King B. Intern Med J. 2007;37:295-302.

The authors surveyed Australian medical practitioners and identified factors limiting their engagement in a systems approach to patient safety, including lack of time, ability to prioritize work, educational opportunities, and a perceived inability to influence the system.

Newspaper/Magazine Article

Is your patient ready to go home?

Hoenig LJ. Med Econ. 2006 Jun 2;83:45-46.

The author discusses the importance of thorough discharge examinations.

Journal Article > Study

Opportunities for performance improvement in relation to medication administration during pediatric stabilization.

Morgan N, Luo X, Fortner C, Frush K. Qual Saf Health Care. 2006;15:179-183.

The investigators observed simulated scenarios to evaluate nurses' clinical performance during medication administration. They found that improvements could be made in several areas, including the use of read-backs and medication preparation, measurement, and selection.

Journal Article > Commentary

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

The author discusses the importance of education in creating a culture of safety and specifically focuses on how human factors theory can be applied to medication administration curricula.

Legislation/Regulation > Fact Sheet/FAQs

FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

ASHE Regulatory Advisory. Chicago, IL: American Society for Healthcare Engineering and the American Society for Healthcare Environmental Services; May 2006.

This advisory suggests that assessing patient risk is a less labor-intensive approach to minimizing bed rail entrapment than the measurement approach recommended by the U.S. Food and Drug Administration.

Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Cases & Commentaries

The Hidden Harms of Hand Sanitizer

  • Web M&M

Stephen Stewart, MBChB, PhD; July 2017

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

Journal Article > Review

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

Mitchell B, Cristancho S, Nyhof BB, Lingard LA. BMJ Qual Saf. 2017 Jun 3; [Epub ahead of print].

Checklists have been heralded as an important tool to improve health care safety. This review examined whether the science supports that recognition. Numerous studies have been published, but the literature base hasn't been developed to fully understand the complexities of surgical checklist implementation programs.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?

Byrne C, Sierra H, Tolhurst R. Br J Nurs. 2017;26:464-467.

Checklists can improve patient safety across multiple settings. This pre–post study found that use of a checklist to help nurses dispense medications upon hospital discharge led to a reduction in errors in discharge prescriptions.

Journal Article > Commentary

Changing the narratives for patient safety.

Pronovost PJ, Sutcliffe KM, Basu L, Dixon-Woods M. Bull World Health Organ. 2017;95:478-480.

Mental models represent established mindsets that can either hinder or enhance safety. This commentary describes mental models about patient safety that may limit progress, such as acceptance of harm as an expected byproduct of medical care. The authors provide suggested changes to these mindsets, including focusing on developing effective patient safety measures and a systems approach to designing and implementing improvement initiatives.

Journal Article > Commentary

Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems.

Clack L, Sax H. Ann Intern Med. 2017;166:HO2-HO3.

Poorly designed systems can contribute to human error. This commentary discusses how applying human factors engineering principles to the care environment can enhance clinician behavior and reduce health care–associated infections.

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