Search results for "Audit and Feedback"

The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.

Although most patient safety efforts have focused on inpatient care, the majority of health care actually takes place in the ambulatory setting. This toolkit for general practitioners in the United Kingdom provides various instruments to help prevent and analyze safety problems. Materials include a trigger tool, medication reconciliation form, and significant event audit template.

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.

The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.

This report reviews injury claim data to assess quality of care in the Veterans Affairs health system.

The Scottish Audit of Surgical Mortality (SASM) facilitates the peer review of all surgical deaths in Scotland. It has the unique distinction of being totally voluntary and involves input from more than 1100 consulting clinicians.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.

Patient safety culture surveys uncover insights into organizational culture and practice areas that require improvement. This selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to survey results.

Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.

Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.

This publication reports recommendations from a focus group exploring the utility of health information technology in enhancing quality measurement and discusses how the data can be used to improve care.

Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.

This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.

This site presents four short films that highlight National Health Service implementation of WalkRounds initiatives, which enable managers and other health care leadership to learn about potential safety problems by engaging with frontline staff.

This AHRQ-funded publication provides a tool to help organizations identify health literacy issues, as well as methods for implementing an action plan drawn from assessment results.

This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.

This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.

This report shares findings from an assessment of Centers for Medicaid and Medicare Services response to nursing home complaints. The report identifies weaknesses in the current investigation process and provides recommendations for improvement.

This government report found that the clinical laboratory survey process is flawed, allowing safety requirements to be bypassed.