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Search results for "Policy Makers"

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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.

Journal Article > Study

Understanding the effect of resident duty hour reform: a qualitative study.

Wu PE, Stroud L, McDonald-Blumer H, Wong BM. CMAJ Open. 2014;2:E115-E120.

Examining concerns about resident duty-hours restrictions in Canada, this interview study found that gaps in clinical care resulting from decreased resident hours were prevalent, particularly in inpatient settings. These findings mirror prior studies in the United States.

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.

Legislation/Regulation > Congressional Testimony

Examining the Increase in Drug Shortages.

Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).

This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.

Journal Article > Review

Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration.

Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Appl Clin Inform. 2017;8:12-34.

The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.

Journal Article > Review

Lost in translation: impact of language barriers on children's healthcare.

Goenka PK. Curr Opin Pediatr. 2016;28:659-666.

Language barriers can contribute to miscommunications that diminish patient safety. This review discusses the responsibility of organizations to identify patients and families that require language assistance and to provide prompt access to qualified interpreters. A past WebM&M commentary discussed how language barriers can compromise quality of care.

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 > Commentary

Capturing essential information to achieve safe interoperability.

Weininger S, Jaffe MB, Rausch T, Goldman JM. Anesth Analg. 2017;124:83-94.

This commentary discusses how clinical scenarios can reveal potential barriers to interoperability between health information systems and medical devices to ensure they are effectively integrated to support safe clinical workflow, process documentation, and data sharing. The authors describe a patient-controlled analgesia failure to illustrate the scenario method. A previous WebM&M commentary discussed risks inherent in lack of system interoperability.

Newspaper/Magazine Article

Measuring patient safety events: opportunities and challenges.

Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.

The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.

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

Transformational leadership in nursing and medication safety education: a discussion paper.

Vaismoradi M, Griffiths P, Turunen H, Jordan S. J Nurs Manag. 2016;24:970-980.

Leadership has an important role in driving and maintaining change in patient safety. This commentary explores existing evidence and expert consensus to identify four characteristics of transformational leaders in nursing that support sustainable improvement in medication safety.

Perspectives on Safety > Interview

In Conversation With… Mark Graban, MS, MBA

Lean and Patient Safety, January 2015

Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.

Perspectives on Safety > Perspective

Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care

with commentary by Paul E. Plsek, MS, Lean and Patient Safety, January 2015

This book excerpt describes how integrating innovation and Lean concepts at Virginia Mason enhances clinical performance and the patient experience.

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.

Journal Article > Commentary

Patient safety goals for the proposed Federal Health Information Technology Safety Center.

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Sittig DF, Classen DC, Singh H. J Am Med Inform Assoc. 2015;22:472-478.

The Institute of Medicine and the Food and Drug Administration have called for the establishment of a national organization to oversee health information technology (IT) safety in the United States. This commentary, written by leaders in the IT field, recommends goals for the proposed Office of the National Coordinator-based Health IT Safety Center, including monitoring and tracking safety events, investigating incidents and disseminating guidance, building a process and infrastructure to examine the safety of health IT systems, and generating support for vigilance around health IT safety in the public and private sectors. The authors also highlight the convening ability of such a center as a critical component for transforming the safety of health IT.

Journal Article > Commentary

Intolerance of error and culture of blame drive medical excess.

Hoffman J, Kanzaria H. BMJ. 2014;349:g5702.

Lack of acceptance for human error and uncertainty have been known to contribute to overdiagnosis and overuse that may result in patient harm. This commentary explains why medical liability reform alone is not sufficient to address this issue. The authors suggest that both professionals and patients will need to adjust their expectations of failures in order to achieve behavior change.

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.

Book/Report

Implications of Health Literacy for Public Health: Workshop Summary.

Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.

Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.

Perspectives on Safety > Perspective

Overuse as a Patient Safety Problem

with commentary by Christopher Moriates, MD, Overuse as a Patient Safety Problem, September 2014

This piece describes the emergence of medical care overuse as a patient safety issue and relates efforts to change clinician behaviors to prevent overtreatment.

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