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Search results for "Policy Makers"

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Journal Article > Review

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.

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Ahmed N, Devitt KS, Keshet I, et al. Ann Surg. 2014;259:1041-1053.

The 2011 duty hour regulations for resident physicians were intended to improve patient safety by reducing resident fatigue. Examining the effects of duty-hours reform on surgical trainees, this systematic review concluded that there were no improvements in patient outcomes. Both perceived education and performance on certification exams have declined following reform, and more frequent handoffs have led to safety concerns. Even though some improvements in residents' quality of life were observed after the first duty-hours reform, the subsequent limitation of 16-hour shifts has not enhanced well-being. The authors express concern about current surgery residency training and urge caution prior to reforming graduate medical education further. A previous AHRQ WebM&M perspective explored the impact of duty hours on patient safety.

Journal Article > Commentary

ACOG Committee Opinion #681: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2016;128:e257-e261.

Disclosure of errors and adverse events is now endorsed by a broad array of organizations. This statement discusses the importance of disclosure and provides resources to help health care organizations develop policies and programs that support a blame-free, learning approach to error that encourages reporting.

Journal Article > Study

Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates.

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Patrick SW, Fry CE, Jones TF, Buntin MB. Health Aff (Millwood). 2016;35:1324-1332.

Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.

Journal Article > Study

State legal restrictions and prescription-opioid use among disabled adults.

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Meara E, Horwitz JR, Powell W, et al. N Engl J Med. 2016;375:44-53.

Growing rates of opioid misuse endanger public health. The impact of legal restrictions to limit high-risk prescribing and resultant adverse events is unclear. One recent study found that opioid-related adverse events were effectively reduced in states with stringent prescription drug monitoring programs compared to states without such regulations. However, this study examined data regarding Medicare beneficiaries with disabilities before and after adoption of controlled-substance laws and found no significant decrease in rates of nonfatal overdose, high opioid doses, or receipt of opioids from four or more prescribers. These results suggest that current regulatory policy may not be sufficient to address high-risk prescribing practices among Medicare beneficiaries with disabilities. More work is needed to develop effective strategies to treat chronic pain safely in this high-risk population. A WebM&M commentary described risks related to prescribing opioids for patients with chronic pain.

Tools/Toolkit > Measurement Tool/Indicator

Patient Safety Project 2015–2017.

Washington, DC: National Quality Forum; December 2015.

The National Quality Forum (NQF) has been a leader in defining patient safety reporting measures. This website provides information about the third cycle of an NQF patient safety project that solicits new measures and will review existing patient safety metrics.  The deadline for submitted appeals on the 13 endorsed measures was February 28, 2017.

Newspaper/Magazine Article

Robotic-assisted surgery: focus on training and credentialing.

Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.

Research has documented a substantial learning curve for surgeons as they develop skills to use robotic technologies. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes the 722 safety events involving robotic-assisted surgery reported since 2005—approximately 75% of these incidents did not result in harm but 10 patient deaths were recorded—and discusses the challenges introduced as robotic-assisted surgery becomes accepted as standard surgical practice.

Journal Article > Commentary

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.

Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS. Am J Public Health. 2014;104:2023-2029.

A substantial number of drug deaths in the United States have been associated with inadvertent overdose of prescription opioids. This commentary explores contributors to iatrogenic opioid addiction, identifies patient characteristics that increase risk of drug dependence, and makes recommendations for education and research to improve safety of chronic pain management.

Journal Article > Study

Investigating the long-term consequences of adverse medical events among older adults.

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Carter MW, Zhu M, Xiang J, Porell FW. Inj Prev. 2014;20:408-415.

Prior studies have shown that older adults are susceptible to adverse medical events both during hospitalization and in the outpatient setting, but few studies have looked at the effects across the health care continuum. Reviewing multiple Medicare databases over a 7-year period, this study found that nearly 1 in 5 older adults experienced at least one adverse event, 62% of which originated in the ambulatory setting. Patients who experienced an adverse medical event had much higher mortality rates, though it should be noted that at baseline these patients were already older and sicker than the other cohort. Medicare expenditures increased sharply during an adverse medical event episode and remained high following the event. This study provides evidence that adverse events have a profound impact that lasts long after the initial incident.

Journal Article > Study

Patient safety in the era of the 80-hour workweek.

Shelton J, Kummerow K, Phillips S, et al. J Surg Educ. 2014;71:551-559.

Regulations intended to reduce resident physicians' work hours have been accompanied by controversy since their introduction in 2003, which mandated an 80-hour workweek for residents. To determine the impact of duty-hours limits on patient safety, researchers evaluated Patient Safety Indicators (PSIs) for postoperative discharges in teaching versus non-teaching hospitals before and after the reform. This study found no clear patterns across PSIs following implementation of duty-hour limits. These results mirror prior studies which have failed to observe an improvement in patient outcomes with reduced resident work hours, suggesting that limiting physician work hours will not be sufficient to augment safety. A previous AHRQ WebM&M perspective discusses the intersection of graduate medical education and patient safety.

Web Resource > Multi-use Website

Patient Safety Measures.

Washington, DC: National Quality Forum.

This Web site tracks the progress of the development and review of measures to enhance reporting and accountability of health care organizations in addressing risks to patient safety.

Journal Article > Study

Primary care closed claims experience of Massachusetts malpractice insurers.

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Schiff GD, Puopolo AL, Huben-Kearney A, et al. JAMA Intern Med. 2013;173:2063-2068.

Malpractice risk in outpatient primary care is increasingly under scrutiny. This study screened malpractice claims from two Massachusetts insurers and found that those from outpatient primary care settings were more likely to be settled or found in favor of the plaintiff compared with those from other practice settings. Similar to previous research, claims related to missed and delayed diagnoses were most frequent, and the most common disease involved was cancer, followed by cardiovascular disease. The accompanying editorial argues that primary care settings will become increasingly important for malpractice claims with the advent of patient-centered medical homes and accountable care organizations, which shift a larger proportion of medical care to the outpatient primary care setting. The authors note a high prevalence of failure-to-diagnose claims and recommend further emphasis on diagnostic safety. A missed diagnosis of myocardial infarction was discussed in an AHRQ WebM&M commentary.

Newspaper/Magazine Article

Drug shortages still at crisis levels.

Talsma J. Drug Topics. June 15, 2013.

Discussing the current state of and efforts to address drug shortages, this news article notes a reduction in chemotherapy delays and reveals persistent barriers to improvement.

Journal Article > Study

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation.

Bell SK, Smulowitz PB, Woodward AC, et al. Milbank Q. 2012;90:682-705.

Some hospital systems have employed a disclosure, apology, and offer strategy for medical errors, with the University of Michigan program being the best described. This model includes full disclosure of adverse events, appropriate investigations, implementation of systems to avoid recurrences, and rapid apology and financial compensation when care is deemed unreasonable. Researchers for this study interviewed key stakeholders and found strong support for more widespread implementation of this model, despite a lack of generalizable data. Benefits for both the liability system and patient safety were discussed, along with substantial challenges to implementation. However, none of the barriers described were felt to be insurmountable. Dr. Albert Wu discusses adverse event disclosure and apologies in an AHRQ WebM&M perspective.

Journal Article > Study

Drug shortage-associated increase in catheter-related blood stream infection in children.

Ralls MW, Blackwood RA, Arnold MA, Partipilo ML, Dimond J, Teitelbaum DH. Pediatrics. 2012;130:e1369-e1373.

National drug shortages have increased and emerged as a serious patient safety issue in the United States. Recently, a shortage of medicinal-grade ethanol occurred due to a temporary shutdown of the sole supplier. Ethanol lock therapy is used to reduce the incidence of catheter-related blood stream infections (CRBSI) in pediatric patients receiving parenteral nutrition due to intestinal failure. Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest that it was likely due to the risk of an impending Food and Drug Administration inspection. During the shortage, the rate of CRBSI at one hospital rose dramatically, resulting in increased lengths of stay and hospital costs. This evidence illustrates profound financial and patient safety implications related to a national drug shortage.

Journal Article > Study

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

Spector WD, Mutter R, Owens P, Limcangco R. Med Care. 2012;50:863-869.

Nearly 1 in 7 elderly patients hospitalized due to traumatic injuries was readmitted within 30 days of discharge, according to this analysis of more than 200,000 admissions. As in prior studies in other patient populations, the risk of readmission was increased for patients who experienced a Patient Safety Indicator event.

Journal Article > Study

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

A subset of trauma patients had a relatively high risk of postoperative venous thromboembolism despite use of appropriate prophylactic measures, calling into question the "wisdom and justice" of classifying this complication as entirely preventable.

Perspectives on Safety > Interview

In Conversation With… Charles Vincent, MPhil, PhD

Safety in the UK, June 2012

Professor Vincent, a psychologist by training, is one of the world’s leading patient safety researchers.

Journal Article > Study

Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?

Raine J, Scarrott D. Eur J Pediatr. 2012;171:1449-1452.

This study discovered that child protection cases and prescribing errors were the most common reasons pediatricians were referred to a governing body overseeing provider performance concerns.

Journal Article > Review

Closed medical negligence claims can drive patient safety and reduce litigation.

Pegalis SE, Bal BS. Clin Orthop Relat Res. 2012;470:1398-1404.

This review evaluates the impact of peer review and tort reform measures on patient safety.

Journal Article > Study

What prevents incident disclosure, and what can be done to promote it?

Iedema R, Allen S, Sorensen R, Gallagher TH. Jt Comm J Qual Patient Saf. 2011;37:409-417.

This Australian study used interviews with clinicians, patients, and families to identify a wide range of barriers to disclosing adverse events. The article provides specific guidance for clinicians, risk managers, and policymakers to promote full disclosure of adverse events.

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