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With scarce access to interpreters, immigrants struggle to understand doctors' orders. | AHRQ Patien
Using professional interpreters can avert risks of miscommunication due to language barriers between patients and clinicians. This news article discusses how lack of qualified medical interpreters, use of ad hoc interpreters, and poor patient understanding of instructions can contribute to adverse events. A WebM M commentary explored patient safety issues associated with patient clinician language differences. -
The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient unit
This before-and-after study examined the impact of a patient safety project which included simulation training, teamwork training, and patient safety educational conferences. The authors found a decrease in hospital-acquired complications, better nurse perceptions of safety culture, and an improved observed-to-expected mortality ratio. These promising preliminary results should spur larger studies of these organizational safety efforts. -
Leveraging trainees to improve quality and safety at the point of care: three models for engagement.
Involving trainees in patient safety work can ground their development in quality improvement. This commentary discusses a three-level framework to engage trainees in quality improvement and patient safety work. The authors review insights regarding strengths and weaknesses of each level of the model and use scenarios to illustrate its use in hospitals. -
Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's ho
Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems. -
A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook. | A
This manual provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care. -
Using Health Information Technology to Support Quality Improvement in Primary Care | PCMH Resource C
Using Health Information Technology to Support Quality Improvement in Primary Care Prepared for: Agency for Healthcare Research and Quality U.S. Depar ... -
A typology of electronic health record workarounds in small-to-medium size primary care practices. |
This ethnographic study used direct observation to characterize how users of an electronic health record compensated for perceived system deficiencies. -
The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in c
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies. -
A program to prevent catheter-associated urinary tract infection in acute care. | AHRQ Patient Safet
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs. -
Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalize
In most training settings, the first physician point-of-contact for a patient with clinical deterioration is a junior doctor who must evaluate the situation and decide whether to alert a supervising physician a process termed escalation of care. Delays in this process can lead to critical failure-to-rescue events, which may result in preventable deaths. This study used ethnographic observations, a risk assessment survey, and a formal health care failure mode and effect and analysis to examine the escalation of care process on surgical wards at three London hospitals. The investigation uncovered 18 hazardous failures, with multiple underlying root causes, including outdated communication technology, insufficient staffing, and challenges related to hierarchy. An extensive list of recommendations to improve these processes is included. A prior AHRQ WebM M commentary discussed some of the pitfalls of hierarchy and the "surgical personality." -
Improving diagnosis in health care the next imperative for patient safety. | AHRQ Patient Safety Net
Diagnostic error received relatively little attention until more recently and is now widely recognized as a major source of patient harm. The National Academy of Medicine (NAM) report, Improving Diagnosis in Health Care, estimated that most United States adults will experience one or more diagnostic errors in their lifetimes. Summarizing the goals from the report, this commentary details how the recommendations from the NAM can lead to enhanced diagnostic safety. The authors also acknowledge potential challenges to implementing the systems and process changes described. An Annual Perspective discussed advances in the field of diagnostic error. -
Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. | AHRQ Patien
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety. -
A Toolset for E-Prescribing Implementation in Independent Pharmacies | AHRQ National Resource Center
You are here Home Tools and Resources Implementation Toolsets for E-Prescribing A Toolset for E-Prescribing Implementation in Independent Pharmacies | ... -
Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. | AHRQ
A multipronged approach used over the past decade at a major academic medical center was unsuccessful in eradicating medical student mistreatment by residents and clinical faculty. The authors point to a widespread culture of disrespect as being a substantial barrier that their intervention was not able to overcome.https://psnet.ahrq.gov/resources/resource/24916 - 8k - 2019-03-31 -
Preventable deaths due to problems in care in English acute hospitals: a retrospective case record r
The famous estimate that 44,000 to 98,000 patients die every year in the United States due to preventable adverse events, which was widely publicized in the Institute of Medicine's seminal report, is challenged as a significant overestimate in this British study. The investigators reviewed 1000 randomly selected deaths from 10 hospitals, using a standardized protocol based on prior classic studies of preventable inpatient mortality and found that only 5.2% of deaths were considered preventable. The majority of preventable deaths occurred in patients whose life expectancy was considered to be less than 1 year even if optimal care was provided. As in prior studies, reviewers' agreement on whether a death was preventable was only moderate. The reviewers did find evidence of significant quality problems among both preventable and non-preventable deaths. -
Look alike/sound alike drugs: a literature review on causes and solutions. | AHRQ Patient Safety Net
Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Consequently, confusion between medications with names that appear or sound similar is a major source of medication errors. The Institute for Safe Medication Practices (ISMP) maintains a list of look-alike and sound-alike drugs, and The Joint Commission mandates that hospitals have systems for preventing these errors as part of its National Patient Safety Goals. Despite awareness of the problem and mandates to address it, this systematic review found a lack of firm data on the incidence of these errors and minimal information regarding effective strategies to avoid them. Although it is plausible that computerized provider order entry should prevent sound-alike errors (which mostly arise from prescribing errors) and the ISMP recommends use of "tall man" lettering to avert look-alike errors, there is no data documenting the effectiveness of these interventions. A previous AHRQ WebM M commentary discussed a look-alike drug error.https://psnet.ahrq.gov/resources/resource/27990 - 8k - 2019-03-31 -
Dual health care system use and high-risk prescribing in patients with dementia: a national cohort s
Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system. -
Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott White Health. | AHRQ Patie
Since the publication of the Institute of Medicine's influential To Err Is Human report, clinicians and policymakers have engaged in efforts to improve patient safety and the quality of health care. This book examines one hospital's approach that focuses on safety culture, process improvement, and technology as key elements of achieving long-term progress in enhancing safety and quality. -
Anticoagulation patient safety goal compliance at a university health system: methods for achieving
This article explains how an academic health care system launched an initiative to accomplish the anticoagulation therapy National Patient Safety Goal. -
Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use i
Patients prescribed opioids and benzodiazepines concurrently may be at increased risk for adverse drug events. Researchers used data from both the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to identify adults already using a benzodiazepine who were newly prescribed opioid medication between 2005 and 2015. Rates of opioid prescribing among patients using a benzodiazepine remained higher than rates in the general population during the entire study period.