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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.

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.

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.

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.

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.

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 > Study

Introductions during time-outs: do surgical team members know one another's names?

Birnbach DJ, Rosen LF, Fitzpatrick M, Paige JT, Arheart KL. Jt Comm J Qual Patient Saf. 2017;43:284-288.

Communication failures in the operating room are a patient safety issue, and knowing other team members' names may help reduce hierarchies that contribute to errors. Introductions are the first step in the surgical time-out in the World Health Organization Surgical Safety Checklist. However, this study—conducted in the operating rooms of three teaching hospitals—suggests that team members often do not know each other's names and may not view introductions as important for maintaining safety.

Journal Article > Study

Mortality trends after a voluntary checklist-based surgical safety collaborative.

Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017 Apr 6; [Epub ahead of print].

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Journal Article > Commentary

Flying lessons for clinicians: developing system 2 practice.

Gregoire JN, Alfes CM, Reimer AP, Terhaar MF. Air Med J. 2017;36:135-137.

Aviation has long served as a model for health care to improve safe practices. Highlighting aviation safety interventions, this commentary suggests that simulation is underutilized in health care training to help nurses to develop deliberate, or system 2, thinking skills. The authors review simulation practices to enhance nursing education strategies that support system 2 reasoning.

Journal Article > Commentary

The CARE approach to reducing diagnostic errors.

Rush JL, Helms SE, Mostow EN. Int J Dermatol. 2017;56:669-673.

Cognitive aids such as checklists and mnemonics can improve process reliability. This project report discusses the development of a mnemonic focused on avoiding diagnostic errors. The authors used the CARE mnemonic (communicate, assess for biased reasoning, reconsider differential diagnoses, enact a plan) as an instruction model to reduce diagnostic errors in their practice.

Journal Article > Commentary

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.

Journal Article > Commentary

The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists.

Clebone A, Burian BK, Watkins SC, Gálvez JA, Lockman JL, Heitmiller ES; Members of the Society for Pediatric Anesthesia Quality and Safety Committee. Anesth Analg. 2017;124:900-907.

Checklists have been highlighted as a cognitive aid to avoid omissions in both routine care and critical events. This commentary describes the development and testing of three critical event checklists in children's hospitals and provides implementation guidance to support their use.

Journal Article > Study

Time-out and checklists: a survey of rural and urban operating room personnel.

Lyons VE, Popejoy LL. J Nurs Care Qual. 2017;32:E3-E10.

Checklists are a cornerstone of patient safety efforts. This cross-sectional survey study examined self-reported adherence to checklists and time-out procedures among operating room staff and found suboptimal implementation in both urban and rural settings. These results underscore the importance of assessing the implementation of evidence-based practices.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Journal Article > Review

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review.

Chen C, Kan T, Li S, Qiu C, Gui L. Am J Emerg Med. 2016;34:2432-2439.

Process and procedure consistency contributes to safe, highly reliable health care. This review examined the literature on the use of standard operating procedures and checklists in prehospital emergency medicine and found encouraging results on safety improvements associated with such interventions in this practice environment.

Newspaper/Magazine Article

Zero tolerance for deadly hospital-acquired infections.

Levine H. Consum Rep. 2017 Jan;82:32-40.

Hospital rating systems have yet to receive approval across the health care industry, but they still serve as a way for consumers to select hospitals and providers. This news article reports on publicly available data for central line infections in hospitals across the United States and spotlights checklists as a strategy that contributes to improvement. The article also ranks teaching hospitals based on their performance at preventing central line infections.

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