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Approach to Improving Safety
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- Health Care Executives and Administrators 12
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Health Care Providers
7
- Nurses 1
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Non-Health Care Professionals
- Information Professionals
Search results for "Information Professionals"
- Information Professionals
- Root Cause Analysis
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Tools/Toolkit > Fact Sheet/FAQs
How to Improve Electronic Health Record Usability and Patient Safety.
Philadelphia, PA: Pew Charitable Trusts; September 6, 2016.
The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.
Journal Article > Study
Creating a web-based incident analysis and communication system.
Marsal S, Heffner JE. J Hosp Med. 2012;7:142-147.
This study reports on the development of a system for standardizing root cause analysis of sentinel events.
Newspaper/Magazine Article
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
Detailing a case in which latent failures led to patient harm, this article encourages health care providers investigating adverse events to consider how both active and latent failures may line up to cause errors.
Cases & Commentaries
Medication Reconciliation Pitfalls
- Web M&M
Robert J. Weber, PharmD, MS; February 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
Journal Article > Commentary
Medical librarians supporting information systems project lifecycles toward improved patient safety.
Saimbert MK, Zhang Y, Pierce J, Moncrief ES, O'Hagan KB, Cole P. J Healthc Inf Manag. 2010;24:52-56.
This commentary describes research and project management skills that medical librarians can contribute to the design and implementation of health information systems that support patient safety.
Cases & Commentaries
Double Dosing, by the Rules
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Journal Article > Review
Can technology improve intershift report? What the research reveals.
Strople B, Ottani P. J Prof Nurs. 2006;22:197-204.
The authors review the literature on shift reports and communication of patient information and discuss how to enhance this process through automation.
Newspaper/Magazine Article
State starts project to track serious hospital mistakes.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
Journal Article > Commentary
Case study: identifying potential problems at the human/technical interface in complex clinical systems.
Caudill-Slosberg M, Weeks WB. Am J Med Qual. 2005;20:353-357.
The authors present a case study to illustrate system vulnerabilities related to computerized physician order entry (CPOE) use.
Journal Article > Study
Anatomic pathology databases and patient safety.
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.
Journal Article > Commentary
Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.
Singh R, Singh A, Fox C, Seldan Taylor J, Rosenthal T, Singh G. Inform Prim Care. 2005;13:135-144.
The authors describe a systems engineering model of analysis and synthesis for understanding error in ambulatory care settings.
Journal Article > Commentary
Lean Six Sigma reduces medication errors.
Esimai G. Qual Prog. April 2005;38:51-57.
The authors analyze one hospital's quality management program. Using a Six Sigma methodology, the program identified policy and practice changes that needed to be implemented in order to reduce harm.
Cases & Commentaries
Hard to Swallow
- Web M&M
Jeffrey Driver, JD, MBA ; October 2004
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.