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Search results for "United States of America"
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Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF.
The growing interest in patient safety in ambulatory care led to the development of the AHRQ Medical Office Survey on Patient Safety Culture, which is designed to assess safety culture in outpatient clinics. This second comparative database report—a prior report was published in 2012—provides descriptive results and benchmarking data derived from more than 27,000 respondents (including clinical and support staff) from 935 clinics. The report identifies several areas of strength: 83% of offices reported having fully implemented electronic medical records, and respondents described high levels of teamwork as well as reliable patient tracking and test follow-up systems. However, as was also found in the 2012 report, many offices reported safety concerns relating to production pressures. The database is freely available from AHRQ for benchmarking and comparison purposes.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Tallahassee, FL: Florida Hospital Association; August 2013.
Chicago, IL: Health Research & Educational Trust; July 2013.
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Shekelle PG, Wachter RM, Pronovost PJ, eds. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 13-E001-EF.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.
Some of the most prominent successes in the patient safety field have been achieved in preventing health care–associated infections. Sponsored by The Joint Commission Center for Transforming Healthcare and the American College of Surgeons, this effort used rigorous quality improvement methodology and a collaborative approach across seven participating hospitals to tackle the problem of surgical site infections (SSIs) in patients undergoing colorectal surgery. The project was a remarkable success, achieving a 32% reduction in SSIs during the study period. The Center for Transforming Healthcare is also sponsoring efforts to prevent wrong-site surgery and improve hand hygiene and handoff communications.
Oakbrook Terrace, IL: Joint Commission.
The Joint Commission's annual report summarizes hospital performance across a broad range of metrics that represent evidence-based standards for high-quality care. These accountability measures have been shown to be directly linked to patient outcomes. Since the report's first publication in 2007, data demonstrates that hospitals have measurably improved quality of care for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Cambridge, MA: Institute for Healthcare Improvement; June 2012.
This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.
Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0042-EF.
This report describes the state of currently available resources to promote patient and family engagement in their health care.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
This monograph provides guidance, tools, and techniques for hospitals to help decrease central line–associated bloodstream infections.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; October 2011. Report No. OEI-01-08-00590.
The Office of the Inspector General (OIG) has conducted a series of analyses of adverse event incidence among Medicare beneficiaries. This report evaluates how hospitals, the Centers for Medicare and Medicaid Services (CMS), and state agencies have responded to particularly serious adverse events. The OIG found that investigations into errors were generally timely and resulted in changes with the potential to improve patient safety. However, the OIG faults state agencies for failing to communicate findings to The Joint Commission and for failing to monitor long-term safety performance at hospitals where errors occurred. The report outlines specific recommendations for CMS and state agencies to ensure that lasting safety improvement comes about after serious errors occur.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
Sculli GL, Sine DM. Danvers, MA: HCPro, Inc; 2011. ISBN: 9781601467836.
This book describes how to apply aviation communication tactics to nursing practice.
Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria.
Shekelle PG, Pronovost PJ, Wachter RM, et al; PSP Technical Expert Panel. Rockville, MD: Agency for Healthcare Research and Quality; December 2010. AHRQ Publication No. 11-0006-EF.
In this report, RAND Health identifies criteria for assessing patient safety practices and presents recommendations for future research on this topic.