Scanning the Headlines: Patient Safety

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Rogith, D. Iyengar, M., and Singh, H. (2017, Nov.). Using fault trees to advance understanding of diagnostic errors. Joint Commission Journal on Quality and Patient Safety. 43(11):598-605. Retrieved from: http://www.jointcommissionjournal.com/article/S1553-7250(17)30041-7/abstract

Szabo, L. (2017, Oct. 23). Treatment Overkill. So much care it hurts: Unneeded scans, therapy, surgery only add to patients' IIls. Kaiser Health News. Retrieved from: https://khn.org/news/so-much-care-it-hurts-unneeded-scans-therapy-surgery-only-add-to-patients-ills/

Rhee, MD, C. Dantes, MD, R., and Esptein, MD, L. (2017, Oct. 3). Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. Journal of American Medical Association (JAMA). 318(13):1241-1249. Retrieved from: http://jamanetwork.com/journals/jama/article-abstract/2654187

(2017, Sept. 12). Inadequate Hand-off Communication. Oakbrook, IL: The Joint Commission. Retrieved from: https://www.jointcommission.org/assets/1/18/SEA_58_Hand_off_Comms_9_6_17_FINAL_(1).pdf

Fisher, K. and others. (2017, Aug.). We want to know: Eliciting hospitalized patients' perspectives on breakdowns in care. Journal of Hospital Medicine. 12(8):1-7. Retrieved from: http://www.journalofhospitalmedicine.com/sites/default/files/Document/August-2017/fisher_0817.pdf

Commins, J. (2017, July 5). Multiple recurring C. Diff. infections on the rise. HealthLeaders Media. Retrieved from: http://www.healthleadersmedia.com/quality/multiple-recurring-c-diff-infections-rise

Terhune, C. (2017, May 24). Putting a lid on waste: Needless medical tests not only cost $200B - They can do harm. Kaiser Health News. Retrieved from: http://khn.org/news/putting-a-lid-on-waste-needless-medical-tests-not-only-cost-200b-they-can-do-harm

Nickelson, D. (2017, May 15). Medical systems hacks are scary, but medical device hacks could be even worse. Harvard Business Review. Retrieved from: https://hbr.org/2017/05/medical-systems-hacks-are-scary-but-medical-device-hacks-could-be-even-worse

Lupkin, S. (2017, May 9). Nearly 1 in 3 recent FDA drug approvals followed by major safety actions. Kaiser Health News. Retrieved from: http://khn.org/news/1-in-3-recent-fda-drug-approvals-followed-by-major-safety-actions

Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP, for the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. Published online May 03, 2017. doi:10.1001/jamasurg.2017.0904

(2017, May). Toolkit to improve safety in ambulatory surgery centers. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/index.html

Jabbarpour, Y., and Finken, J. (2017, Apr. 28). Psychiatric leadership and collaboration toward a culture of safety. Psychiatric News. Retrieved from: http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.4b4

Ross, C. (2017, Mar. 20). When Hospital Inspectors are in Town, Fewer Patients Die, Study Says. Boston, MA: STAT. Retrieved from: https://www.statnews.com/2017/03/20/hospital-inspectors-fewer-patients-die

Wynn, M., and Fauber, J. (2017, Mar. 18). Analysis: Reports of drug side effects increase fivefold in 12 years. Milwaukee -Wisconsin Journal Sentinel. Retrieved from: http://www.jsonline.com/story/news/investigations/2017/03/17/analysis-reports-drug-side-effects-see-major-increase/99211376/

(2017, Mar. 1). Sentinel Alert Event: The Essential Role of Leadership in Developing a Safety Culture. Oakbrook Terrace, IL: The Joint Commission. Retrieved from: https://www.jointcommission.org/assets/1/18/SEA_57_Safety_Culture_Leadership_0317.pdf

Smith, S., Yount, N., and Sorra, J. (2017, Feb. 16). Exploring relationships between hospital patient safety culture and consumer reports safety scores. BMC Health Services Research. Retrieved from: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2078-6

Obermeyer, Z., and others. (2017, Feb.). Early death after discharge from emergency departments: analysis of national US insurance claims data. British Medical Journal. Retrieved from: http://www.bmj.com/content/356/bmj.j239

Gupta, K., and Lyndon, A. (2017, Feb.). Rethinking Root Cause Analysis. Washington: U.S. Department of Health and Human Services. Retrieved from: https://psnet.ahrq.gov/perspectives/perspective/216

(2017, Jan.). Toolkit to Improve Safety for Mechanically Ventilated Patients. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/mvp/index.html

Black, B., Wagner, A., and Zabinski, Z. (2017). The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas. American Journal of Health Economics. 3(2):109-139. Retrieved from: http://www.mitpressjournals.org/doi/pdf/10.1162/AJHE_a_00069

(2017). The Hospital Checklist: How Social Science Insights Improve Health Care Outcomes. Washington: National Academy of Sciences. Retrieved from: https://www.nap.edu/read/23510/

NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute. Americans’ Experiences with Medical Errors and Views on Patient Safety. 2017. http://www.ihi.org/about/news/Pages/New-Survey-Looks-at-Patient-Experiences-With-Medical-Error.aspx

(2017). ISMP Medication Safety Self-Assessment® for High-Alert Medications. Horsham, PA: Institute for Safe Medication Practices. Retrieved from: http://www.ismp.org/selfassessments/saham/

(2016, Dec.). National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html

Nuckols, T., Keeler, E., and Morton, S. (2016, Dec.) Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters. Journal of American Medical Association. 176(12):1843-1854. Retrieved from: http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2571616

Branswell, H. (2016, Oct. 25). Hospitals installed more sinks to stop infections. The sinks can make the problem worse. STAT. Retrieved from: https://www.statnews.com/2016/10/25/hospital-sinks-infections/

Budryk, Z. (2016, Oct. 24). How can IT companies work with hospitals and physicians for a smooth cloud transition? FierceHealthcare. Retrieved from: http://www.fiercehealthcare.com/healthcare/rural-hospitals-lead-infection-prevention

Joynt, K., and others. (2016, Oct. 19). ASPE Issue Brief: Rural Hospital Participation and Performance In Value-Based Purchasing and Other Delivery System Reform Initiatives. Washington: Department of Health and Human Services. Retrieved from: https://aspe.hhs.gov/sites/default/files/pdf/211061/RuralHospitalsDSR.pdf

Cassini, A., and others. (2016, Oct. 18). Burden of six healthcare-associated infections on European population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study. PLOS Medicine. Retrieved from: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002150

DeBakey, M. (2016, Oct. 18). Annals for hospitalists inpatient notes - reducing diagnostic error - a new horizon of opportunities for hospital medicine. Annals of Internal Medicine. Retrieved from: http://annals.org/aim/article/2569422/annals-hospitalists-inpatient-notes-reducing-diagnostic-error-new-horizon-opportunities

(2016, Oct.). Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project. Chicago: American Hospital Association. Retrieved from: http://www.hpoe.org/Reports-HPOE/2016/preventing-patient-falls.pdf

(2016, Sept.). Fatigue, Sleep Deprivation, and Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://psnet.ahrq.gov/primers/primer/37

(2016, Sept.). How to Improve Electronic Health Record Usability and Patient Safety. Washington: The PEW Charitable Trusts. Retrieved from: http://www.pewtrusts.org/~/media/assets/2016/08/usability_conference_fs.pdf

McAlearney, A.S., and others. (2016, July-Sept.). Toward a high-performance management system in health care, part 4: Using high-performance work practices to prevent central line-associated blood stream infections – a comparative case study. Health Care Management Review, 41(3), 233-243.

Gorman, A. (2016, Aug. 30). 'America's other drug problem': Copious prescriptions for hospitalized elderly. Kaiser Health News. Retrieved from: http://khn.org/news/americas-other-drug-problem-copious-prescriptions-for-hospitalized-elderly/

Maynard, G. (2016, Aug.). Preventing Hospital-Associated Venous Thromboembolism A Guide for Effective Quality Improvement. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf

Commins, J. (2016, July 20). Can automated prompts reduce surgical site infections? HealthLeaders Media. Retrieved from: http://www.healthleadersmedia.com/community-rural/can-automated-prompts-reduce-surgical-site-infections

Luthra, S. (2016, June 15). Screen flashes and pop-up reminders: 'Alert fatigue' spreads through medicine. Kaiser Health News. Retrieved from: http://khn.org/news/screen-flashes-and-pop-up-reminders-alert-fatigue-spreads-through-medicine

Kronick, R., Arnold, S., and Brady, J. (2016, June 13). Improving safety for hospitalized patients: Much progress but many challenges remain. Journal of American Medical Association. Retrieved from: http://jama.jamanetwork.com/article.aspx?articleid=2528945

Beck, M. (2016, June 6). Why many hospitals are banning flowers and balloons. The Wall Street Journal. Retrieved from: http://www.wsj.com/articles/why-many-hospitals-are-banning-flowers-and-stuffed-animals-1465234611

Saint, S., and others. (2016, June 2). A program to prevent catheter-associated urinary tract infection in acute care. New England Journal of Medicine. 374:2111-2119. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMoa1504906

Pronovost, P., Watson, S., and others. (2016, May/June). Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units. American Journal of Medical Quality. 31(3):197-202. Retrieved from: http://ajm.sagepub.com/content/31/3/197.abstract

Green, M. (2016, May 31). Should your ICU patients wear ear plugs? Becker's Infection Control & Clinical Quality. Retrieved from: http://www.beckershospitalreview.com/quality/should-your-icu-patients-wear-ear-plugs.html

Paddock, C. (2016, May 11). Linking hospital patient deaths to weekend staffing a major 'oversimplification'. Medical News Today. Retrieved from: http://www.medicalnewstoday.com/articles/310127.php

Cummings, K., and others. (2016, May 10). Addressing infection prevention and control in the first U.S. community hospital to care for patients with Ebola Virus Disease: Context for national recommendations and future strategies. Annal Internal Medicine. Retrieved from: http://annals.org/article.aspx?articleid=2521614

Makary, M., and Daniel, M. (2016, May 3). Medical error-the third leading cause of death in the US. British Medical Journal. Retrieved from: www.bmj.com/content/353/bmj.i2139

Famolaro, T., and others. (2016, May). Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: Part I: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/2016/mosurvey2016pt1.pdf Part II: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/2016/mosurvey2016pt2.pdf

Graber, M., Johnston, D., and Bailey, R. (2016, May). Report of the Evidence on Health IT Safety and Interventions. Research Triangle Park, NC: RTI International. Retrieved from: https://www.healthit.gov/sites/default/files/task_8_1_final_508.pdf

Graber, M., Bailey, R., and Johnston, D. (2016, May). Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Research Triangle Park, NC: RTI International. Retrieved from: https://www.healthit.gov/sites/default/files/task_9_report.pdf

(2016, May). Resident Safety Practices in Nursing Home Settings. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://www.effectivehealthcare.ahrq.gov/ehc/products/621/2224/nursing-home-safety-report-160510.pdf

Doyle, P., Gurses, A., and Pronovost, P. (2016, Apr. 27). Mastering medical devices for safe use. American Journal of Medical Quality. Retrieved from: http://ajm.sagepub.com/content/early/2016/04/26/1062860616645857.extract

(2016, Apr. 26). A Path to Better Antibiotic Stewardship in Inpatient Settings. Philadelphia, PA: The Pew Charitable Trusts. Retrieved from: http://www.pewtrusts.org/en/research-and-analysis/reports/2016/04/a-path-to-better-antibiotic-stewardship-in-inpatient-settings

Ready, T. (2016, Apr. 21). Does measuring quality really ensure patient safety? HealthLeaders Media. Retrieved from: http://www.healthleadersmedia.com/quality/does-measuring-quality-really-ensure-patient-safety

Sandora, T., Fung, M., and Melvin, P. (2016, Apr. 18). National variability and appropriateness of surgical antibiotic prophylaxis in US children's hospitals. Journal of the American Medical Association. Retrieved from: http://archpedi.jamanetwork.com/article.aspx?articleid=2513202

Jha, A., and Pronovost, P. (2016, Apr. 14). Toward a safer health care system. Journal of the American Medical Association. Retrieved from: http://jama.jamanetwork.com/article.aspx?articleid=2514090

(2016, Apr. 13). New Quick Safety Focuses on Implicit Bias. Oakbrook Terrace: Joint Commission. Retrieved from: http://www.jointcommission.org/issues/article.aspx?Article=TjgKCr9s%2b3VowCidQsb%2bE4yZbhTavTj%2fu0vzpKVtAHk%3d

(2016, Apr.). Patient Safety Primer: Trigggers and Trigger Tools. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://psnet.ahrq.gov/primers/primer/33

(2016, Apr.). Top 10 Patient Safety Concerns for Healthcare Organizations 2016: Executive Brief. Plymouth Meeting, PA: ECRI Institute. Retrieved from: www.ecri.org/patientsafetytop10.

(2016, Mar.). Organizational Leadership and Its Role in Improving Safety. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://psnet.ahrq.gov/primers/primer/32?utm_source=EN&utm_medium=EN&utm_term=1&utm_content=8&utm_campaign=AHRQ_PSP_2016

(2016, Mar.). Priorities in Focus-Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/workingforquality/reports/priorities-in-focus-march2016.html

(2016, Mar.). Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: https://www.effectivehealthcare.ahrq.gov/ehc/products/604/2208/c-difficile-update-report-160329.pdf

(2016, Mar.). Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf

(2016, Feb. 25). Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices. GAO-16-308. Washington: U.S. Government Accountability Office. Retrieved from: http://www.gao.gov/products/GAO-16-308

Bailey, M. (2016, Feb. 1). Communication failures linked to 1,744 deaths in five years, US malpractice study finds. STATS News. Retrieved from: http://www.statnews.com/2016/02/01/communication-failures-malpractice-study/

(2016, Feb.). Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. Plymouth Meeting, PA: ECRI Institute. Retrieved from: https://www.ecri.org/resource-center/Pages/HIT-Safe-Practices.aspx

Trzeciak, S., Gaughan, J., and others. (2016). Association between Medicare summary star ratings for patient experience and clinical outcomes in US hopsitals. Journal of Patient Experience. Retrieved from: http://jpx.sagepub.com/content/3/1/2374373516636681.full.pdf+html

(2016). Busting the Myths about Engaging Patients and Families in Patient Safety. Oakbrook Terrace, IL: The Joint Commission. Retrieved from: https://www.jointcommission.org/assets/1/18/PFAC_patient_family_and_safety_white_paper.pdf