Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Practice Guidelines"

1 - 20 of 42 results
Download Selected Citations

Show: 20 | 50 | 100

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Journal Article > Study

Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.

Kachalia A, Little A, Isavoran M, Crider LM, Smith J. Health Aff (Millwood). 2014;33:59-66.

This study found that proposed safe harbor legislation—liability protection for physicians who followed certain guideline recommendations—would have changed the outcome of closed liability claims only 1% of the time. The real benefit of this legislation may be increased clinician adherence to guidelines.

Newspaper/Magazine Article

Delivering safety over convenience.

Clark C. HealthLeaders Media. September 13, 2013.

This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.

Cases & Commentaries

Outbreak

  • Web M&M

Richard Rothman, MD, PhD; Sahael Stapleton, MD; May 2011

An emergency department worker develops chicken pox following an exposure during one of his shifts.

Journal Article > Study

Professional values and reported behaviours of doctors in the USA and UK: quantitative survey.

Roland M, Rao SR, Sibbald B, et al. BMJ Qual Saf. 2011;20:515-521.

This survey found significant differences between American and British physicians regarding several aspects of patient safety, including appropriateness of error disclosure, tolerance for disruptive behavior, and prior experience with formal patient safety training.

Cases & Commentaries

One Toxic Drug Is Not Like Another

  • Spotlight Case
  • Web M&M

Eric S. Holmboe, MD; February 2011

A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.

Cases & Commentaries

Defensive Medicine: "Glowing" with Pain

  • Web M&M

Manish K. Sethi, MD; February 2010

Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.

Journal Article > Commentary

Balancing "no blame" with accountability in patient safety.

  • Classic

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.

Journal Article > Commentary

Disclosing errors that affect multiple patients.

Chafe R, Levinson W, Sullivan T. CMAJ. 2009;180:1125-1127.

This commentary describes strategies for disclosing medical errors at an institutional level.

Book/Report

Adverse Events in Hospitals: Overview of Key Issues.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.

The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.

Perspectives on Safety > Perspective

Identifying Adverse Events Not Present on Admission: Can We Do It?

with commentary by James M. Naessens, ScD, Not Paying for Errors: A Policy Perspective, October 2008

Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.

Perspectives on Safety > Interview

In Conversation with…Robert M. Wachter, MD

Not Paying for Errors: A Policy Perspective, October 2008

At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.

Press Release/Announcement

The MacArthur Fellows Program: Peter Pronovost.

The John D. and Catherine T. MacArthur Foundation. September 23, 2008.

Through his work, Peter Pronovost, a critical care physician and professor at Johns Hopkins University School of Medicine, has inspired culture change by devising evidence-based clinical practices that save lives and improve patient safety. The MacArthur Foundation has selected him as a 2008 Fellow and recipient of a $500,000 "genius grant."

Newspaper/Magazine Article

Geisinger Health System's plan to fix America's health care.

Carbonara P. Fast Company. October 2008.

This magazine article describes how one health system is using an evidence-based, pay-for-performance program to reduce errors and improve outcomes in coronary-artery bypass graft (CABG) surgery.

Cases & Commentaries

Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad

  • Spotlight Case
  • Web M&M

Sumant Ranji, MD; April 2008

A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.

Book/Report

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.

Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.

This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.

Book/Report

Canadian Disclosure Guidelines.

Windwick B, Vallet D, Beard P, et al; Disclosure Working Group. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2008. ISBN: 0973927011.

These national guidelines for Canadian health care providers serve as a tool for developing and implementing disclosure policies, practices, and training methods.

Journal Article > Commentary

Complying with the 2008 national patient safety goals.

Catalano K, Fickenscher K. AORN J. 2008;87:547-549, 552-556.

This article reviews the Joint Commission's National Patient Safety Goals and describes ways in which information technology can aid in achieving these goals.

Legislation/Regulation > Organizational Policy/Guidelines

Disclosure of Adverse Events to Patients.

Veterans Health Administration. Washington DC: Department of Veterans Affairs; October 27, 2005. VHA Directive 2008-02.

This Veterans Health Administration (VHA) directive provides direction for disclosing medical mistakes to patients and their families. The policy addresses actions that specific VHA staff members should take during the disclosure process.

Journal Article > Commentary

Improving patient care by linking evidence-based medicine and evidence-based management.

Shortell SM, Rundall TG, Hsu J. JAMA. 2007;298:673-676.

This article discusses the importance of integrating clinical evidence into routine practice and how such management can improve safety.

Back to Top