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Search results for "Policy Makers"

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Journal Article > Study

Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field.

Chen Q, Shin MH, Chan JA, et al. Am J Med Qual. 2016;31:178-186.

This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.

Perspectives on Safety > Perspective

African Partnerships for Patient Safety: Lessons Learned

with commentary by Shams B. Syed, MD, MPH, Global Patient Safety, December 2014

This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.

Newspaper/Magazine Article

Hospitals often ignore policies on using qualified medical interpreters.

Rice S. Mod Healthc. 2014;44:16-18, 20.

Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.

Tools/Toolkit > Measurement Tool/Indicator

ISMP National Vaccine Error Reporting Program.

Horsham, PA: Institute for Safe Medication Practices.

This reporting program collects data on errors and concerns associated with vaccines.

Award

2012 John M. Eisenberg Patient Safety and Quality Awards.

Jt Comm J Qual Patient Saf. 2013;39:243-266.

Spotlighting the accomplishments of the 2012 recipients of the John M. Eisenberg Patient Safety and Quality Awards, this issue includes an interview with Saul Weingart, MD, PhD, as well as articles on programs at Kaiser Permanente (Oakland, CA) and Memorial Hermann Health System (Houston, TX).

Book/Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2011.

Oakbrook Terrace, IL: The Joint Commission; September 2011.

This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.

Journal Article > Commentary

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

Highlighting goals and strategies of the Partnership for Patients program, this commentary discusses challenges to improving patient safety.

Book/Report

2015 MHA Patient Safety and Quality Annual Report.

Okemos, MI: Michigan Health & Hospital Association; October 2015.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. Achievements covered in the current year include a reduction in patient readmissions and continued improvements in the incidents of central-line-associated bloodstream infections.

Book/Report

Hospital Reporting Program: Annual Summary.

Portland, OR: Oregon Patient Safety Commission.

This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.

Book/Report

Patient Safety Culture Report: Focusing on Indicators.

Utrecht, Netherlands: European Network for Patient Safety; 2010.

This report identifies care process and outcome indicators in the European Union and describes how the indicators relate to patient safety culture.

Book/Report

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

  • Classic

Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.

The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.

Book/Report

Advances in Patient Safety: New Directions and Alternative Approaches.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).

The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.

Journal Article > Commentary

The tension between needing to improve care and knowing how to do it.

  • Classic

Auerbach AD, Landefeld CS, Shojania KG. N Engl J Med. 2007;357:608-613.

Since the publication of the Institute of Medicine's influential To Err Is Human report in 1999, clinicians and policymakers have embarked on an unprecedented quest to improve patient safety and the quality of health care. While some successes have been achieved, the best methods of improving care remain uncertain, and tension exists between those advocating for rapid dissemination of innovative strategies and those calling for evaluation of such strategies via clinical trials before dissemination. In this commentary, the authors outline arguments supporting and opposing each approach. They conclude that quality improvement interventions should be held to the same standards for determining effectiveness as other medical therapies, and use examples of recent patient safety interventions to illustrate the possible unintended consequences of ineffective initiatives.

Journal Article > Commentary

Our broken health care system and how to fix it: an essay on health law and policy.

Jost TS. Wake Forest Law Rev. 2006;41:537-618.

The author discusses problems in the U.S. health care system and laws that govern this system and provides a legal framework for reform.

Journal Article > Commentary

Making patient safety the centerpiece of medical liability reform.

Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.

This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.

Journal Article > Commentary

Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.

Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.

The author presents a legal discussion on public access to physician information, arguing that Congress should allow consumers to access certain information while still protecting error information in order to promote error reporting.

Perspectives on Safety > Perspective

The Unintended Consequences of Florida Medical Liability Legislation

with commentary by Paul Barach, MD, MPH , The Law and Patient Safety, December 2005

Quality health care and patient safety have emerged as major concerns in society. The Institute of Medicine’s report entitled To Err is Human: Building a Safer Health System led to considerable discussion in both the public and private sectors on the need...

Journal Article > Review

Patient safety in cataract surgery.

Kelly SP, Astbury NJ. Eye. 2006;20:275-282.

The authors evaluate patient safety issues involved with cataract surgery and provide several recommendations for safety improvement, including developing a culture of safety and reviewing critical incidents.

Journal Article > Commentary

Five years after 'To Err is Human': what have we learned?

  • Classic

Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.

Two of the leaders in the patient safety movement, Lucian Leape and Donald Berwick, share their perspectives on the progress made since the Institute of Medicine's (IOM) release of To Err is Human. They summarize the shifts in thinking that have occurred, from blaming individual physicians towards targeting systems as a method to improve both quality and safety. Discussion includes the evolution of error prevention strategies, the role of interested stakeholders in the safety movement, and the impact of implementing best practices. Barriers to ongoing progress are also shared, including the increasing complexity of health care, a tradition of autonomy in care, and the current financial incentive systems. The authors provide a vision for the next five years with expectations for rapid change in adoption of electronic medical records, teamwork training, and full disclosure to patients. While they applaud several efforts and initiatives, such as the growth of AHRQ-funded research, the authors call for a rededication of providers and policymakers to the cause of patient safety, promoted by increased funding, better alignment of incentives, and the setting of ambitious but achievable safety targets.

Newspaper/Magazine Article

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

This article highlights a commentary published in JAMA by two leading experts in patient safety which summarizes the progress made since publication of the landmark To Err is Human report in 2000.

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