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Search results for "Policy Makers"

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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).

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

Advances in Patient Safety: New Directions and Alternative Approaches.

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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 > Study

An acetaminophen icon helps reduce medication decision errors in an experimental setting.

Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.

Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.

Journal Article > Study

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

Schroeder SR, Salomon MM, Galanter WL, et al. BMJ Qual Saf. 2017;26:395-407.

Look-alike and sound-alike drug names are a concerning source of confusion and medication errors. Although drug names currently undergo tests to assess their potential for confusion prior to approval, these tests have not reliably predicted real-world error rates. This study describes the development and validation of four drug name memory and perception laboratory tests. Eighty participants completed the tests and their results were analyzed against actual errors in two large outpatient pharmacy chains. The laboratory tests performed very well, demonstrating a strong association between drug name confusion errors seen during testing and those observed in real-world experience. The authors suggest that regulators and drug companies consider using these tests prior to approval of new drug names.

Journal Article > Commentary

Medical error—the third leading cause of death in the US.

Makary MA, Daniel M. BMJ. 2016;353:i2139.

How many patients die each year due to preventable adverse events is difficult to determine. Early studies summarized in the seminal To Err Is Human report yielded an estimate of 44,000 to 98,000 deaths due to errors yearly. More recent studies have challenged that estimate. A recent British study found that only 3.6% of inpatient deaths were potentially avoidable, which translates to approximately 26,000 preventable deaths each year in the United States. This commentary argues that preventable deaths total more than 250,000 deaths per year, which would rank medical errors as the third most common cause of death. This estimation was developed by extrapolating preventable death rates from several studies with different methodologies to estimate avoidable adverse events; no formal meta-analysis was performed. It is important to note that discerning the preventability of adverse events (and consequent deaths) is difficult. Most studies of preventable harm find that even experienced clinical reviewers achieve only moderate interrater agreement on whether an adverse event occurred and, if so, whether it contributed to death. Although this article's estimate is likely to be controversial, the authors do highlight the lack of accurate strategies for measuring safety events—a problem also highlighted in a recent commentary by two patient safety leaders. Regardless of the exact number, too many patients die needlessly due to unsafe care.

Journal Article > Commentary

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

Singh H, Sittig DF. BMJ Qual Saf. 2015;24:103-110.

This commentary describes a three-element framework to enable study and evaluation of diagnostic errors. The model considers the sociotechnical process through which diagnosis happens, the external factors that influence the patient–clinician encounter, and the postdiagnosis patient outcomes to define measures.

Journal Article > Study

Patient safety skills in primary care: a national survey of GP educators.

Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.

There is a consensus that training in patient safety must be integrated into medical education, but less agreement on the core skills that students should be taught. A prior study used a consensus approach to identify the key attributes of a safe practitioner. In this study, a group of educational supervisors of primary care trainees in the United Kingdom were surveyed regarding how they perceived the importance of each of these skills. Clinicians identified many nontechnical skills as being essential for safe practice, including conscientiousness and situational awareness, and agreed that these abilities could be taught through formal curricula. The concepts explored in this study have been used to develop a patient safety curriculum that is being implemented widely in the United Kingdom.

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.

Web Resource > Government Resource

Betsy Lehman Center for Patient Safety and Medical Error Reduction.

Center for Health Information and Analysis.

The Betsy Lehman Center is an independent organization named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.

Book/Report

The Public's Views on Medical Error in Massachusetts.

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Boston, MA: Harvard School of Public Health; December 2014.

This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.

Journal Article > Commentary

Public reporting of patient safety metrics: ready or not?

Podolsky DK, Nagarkar PA, Reed WG, Rohrich RJ. Plast Reconstr Surg. 2014;134:981e-985e.

Despite the perceived value of publicly available quality and safety data, concerns have been raised about their effectiveness. Reviewing the evidence on existing patient safety measures, this commentary explores the accuracy, validity, and usefulness of information reported. The authors suggest that clinicians and health care consumers be involved in designing metrics and collecting data to improve public reporting systems.

Book/Report

America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2014.

Oakbrook Terrace, IL: The Joint Commission; November 2014.

This Joint Commission annual report shows continued improvements in quality of care in hospitals across the United States. This year's list of Top Performers included a record 1224 hospitals, representing nearly 37% of all reporting Joint Commission-accredited hospitals. Even as The Joint Commission has added new accountability measures over the past few years for stroke care, venous thromboembolism, perinatal care, and immunizations, the number of hospitals reaching at least a 95% composite accountability score has more than tripled in the past 4 years. Major gains were found this year in the quality of perinatal care, children's asthma, venous thromboembolism, and inpatient psychiatric services. Heart attack care now has a composite score of 99%.

Book/Report

Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health.

London, UK: Frontier Economics Ltd; October 2014.

This report provides an overview of evidence on preventable adverse events in the National Health Service and estimates that health care–acquired patient harm results in £1 to £2.5 billion in extra costs annually.

Journal Article > Review

Patient safety challenges in low-income and middle-income countries.

Steffner KR, McQueen KAK, Gelb AW. Curr Opin Anaesthesiol. 2014;27:623-629.

The need for surgical treatment is increasing globally. Examining health care safety in developing countries, this review underscores the need for better access to trained anesthesia providers and for research and policy to address weaknesses related to existing disparities, infrastructure, and data collection to guide improvement efforts.

Newspaper/Magazine Article

Awareness of patient safety grows with increased outpatient surgeries.

Aston G. Hosp Health Netw. September 9, 2014.

As outpatient surgery becomes more prevalent, attention around related safety concerns grows. This news article highlights federally supported initiatives that utilized reporting incentives and surgical safety checklists to improve safety in ambulatory surgery centers.

Audiovisual > Audiovisual Presentation

The State of VA Health Care.

Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014). (Testimony of Richard Griffin; Robert A. McDonald.)

In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.

Journal Article > Study

Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM.

Boyd AD, Yang YM, Li J, et al. J Am Med Inform Assoc. 2015;22:19-28.

Administrative data generated for billing purposes is often used as a means of detecting adverse events. This method is limited by the fact that the ICD-9 diagnosis coding system does not specifically define many common adverse events, and as a result AHRQ developed the Patient Safety Indicators (PSIs) to screen administrative data for this purpose. The updated ICD-10 coding system will be implemented nationwide in the United States in 2015. The Centers for Medicare and Medicaid Services has proposed translations of the PSIs for ICD-10, but this study found substantial inaccuracies when ICD-10-based administrative data was screened using these translations. For example, the PSI for pressure ulcers demonstrated a high false-negative rate, meaning that ICD-10 based data will likely under-report the true incidence of this never event. Other PSIs demonstrated the opposite problem—potential for over-reporting due to a high false-positive rate—and some PSIs have greater potential for variability in interpretation by coders due to the substantially larger number of diagnoses included in ICD-10 (a problem noted in a prior systematic review). The results of this study raise serious concerns about the validity of administrative data for measuring patient safety in the ICD-10 era.

Web Resource > Government Resource

Serious Reportable Events.

Nova Scotia Department of Health and Wellness.

Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to information about serious adverse events reported to the Department of Health and Wellness in Nova Scotia related to surgical procedures, product or device use, patient harm, care management, and hospital environment.

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