© EOS Surfaces and EOScu Blog, 2014. 12, No. Currently, she is a risk manager at Northwestern Memorial Hospital in Chicago. Failure to rescue, defined as the death of a patient after one or more potentially treatable complications, is being used as a surgical quality indicator to account for potentially preventable postoperative complications. 1, 21 October 2020 | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Vol. In the years since the report’s publication, it has become increasingly clear that safety issues are pervasive throughout health care and that patients are frequently injured as a result of the care they receive. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. 17, No. When measures are inaccurate, as was the case with many of the Patient Safety Indicators,62 public reporting of harm rates can provide the wrong picture of which organizations are delivering safe care, which can lead patients to make the wrong choices and adversely affect the organizations. Patient safety in the office-based practice setting, The economics of patient safety in primary and ambulatory care: flying blind, Application of electronic health records to the Joint Commission’s 2011 National Patient Safety Goals, Electronic health records and national patient-safety goals, Wright A, Ai A, Ash J, Wiesen JF, Hickman TT, Aaron S, Clinical decision support alert malfunctions: analysis and empirically derived taxonomy, Characterizing the source of text in electronic health record progress notes, Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Sittig DF, Information overload and missed test results in electronic health record-based settings. To err is human: building a safer health system, Improving patient safety—five years after the IOM report, Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW, A new, evidence-based estimate of patient harms associated with hospital care, Medical error—the third leading cause of death in the US, Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer, Estimating deaths due to medical error: the ongoing controversy and why it matters, Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Eliminating catheter-related bloodstream infections in the intensive care unit, Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, An intervention to decrease catheter-related bloodstream infections in the ICU, The ongoing quality improvement journey: next stop, high reliability, Shabot MM, Chassin MR, France AC, Inurria J, Kendrick J, Schmaltz SP, Using the Targeted Solutions Tool® to improve hand hygiene compliance is associated with decreased health care-associated infections, National scorecard on rates of hospital-acquired conditions 2010 to 2015: interim data from national efforts to make health care safer, Pronovost PJ, Cleeman JI, Wright D, Srinivasan A, New data shows infection rates still too high in U.S. hospitals, Pham JC, Goeschel CA, Berenholtz SM, Demski R, Lubomski LH, Rosen MA, CLABSI conversations: lessons from peer-to-peer assessments to reduce central line–associated bloodstream infections, Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Incidence of adverse drug events and potential adverse drug events. 12, 23 February 2019 | Archives of Disease in Childhood, Vol. For example, 75 percent of US hospitals had a standardized infection ratio above the Leapfrog Group’s standard in one recent evaluation.14 Much of the remaining variation in hospital infection rates is believed to result from inconsistency in the use of prevention techniques. These elements are a reliable and valid measurement system, evidence-based care practices, investment in implementation sciences, local ownership and peer learning communities, and alignment and synergy efforts around a common goal and measures. 1. by Improved hand washing has also been an important part of this effort.11 In fact, the number of hospital-acquired conditions fell from 145 per 1,000 admissions in 2010 to 115 per 1,000 admissions in 2015, as assessed by the AHRQ national scorecard.12 The rate of central line–associated bloodstream infections appears to have fallen by about 80 percent since the publication of To Err Is Human.13, While effective prevention strategies are now available, infection rates remain too high. 9, Journal of Patient Safety and Infection Control, Vol. 95, No. The result is that knowledge in this area is nascent, and there are only a few generalizable interventions. Implications for prevention, Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review, Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI, Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis, Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Effect of bar-code technology on the safety of medication administration, Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy, Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ, A cost-benefit analysis of electronic medical records in primary care, A new sociotechnical model for studying health information technology in complex adaptive healthcare systems, Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, A surgical safety checklist to reduce morbidity and mortality in a global population, Taylor SL, Dy S, Foy R, Hempel S, McDonald KM, Ovretveit J. Progress in addressing other hospital-acquired adverse events has been variable. Amazon配送商品ならTo Err Is Human: Building a Safer Health Systemが通常配送無料。更にAmazonならポイント還元本が多数。Institute of Medicine (U.s.), Corrigan, Janet M., Donaldson, Molla S.作品ほ … However, recent data suggest that clinical decision support in EHRs is not delivering the benefits seen in earlier studies, and that it might not be having any impact at all as currently implemented—which makes this a critical priority to address.22 Work-arounds remain a pervasive issue with technologies such as bar coding: People employ work-arounds to save time in part because they might not appreciate the safety benefits. This would facilitate complex, cross-patient queries to help identify areas for improvement and monitoring. Health systems must start to expand their patient safety capacity and infrastructure to meet the demands of emerging safety issues, address recommendations from policy makers and other national stakeholders, and implement newly developed best practices. 15, No. 1, 9 July 2019 | Drug Safety, Vol. 0 Comments. These organizations bring groups together to improve wider learning by sharing data from voluntary reporting under privacy and confidentiality protection.30 Often they coalesce around a specific domain such as health information technology (IT) safety. Preventable harm is a major cause of preventable death worldwide. Specifically, computerizing the ordering of medications and delivering computerized clinical decision support to the ordering provider has been found to reduce rates of adverse drug events.17–19 Decision support includes checking orders for allergies and flagging drugs with risky interactions or out-of-range dosages and then making corrective suggestions to providers in real time. Number of times cited according to CrossRef: 17 Jawahar Kalra, Daniel Markewich, Patrick Seitzinger, Quality Assessment and Management: An Overview of Concordance and Discordance Rates Between Clinical and Autopsy Diagnoses, Advances in Human Factors and Ergonomics in Healthcare … Moreover, even well-thought-out interventions inevitably create new challenges and unforeseen safety issues. Some of the principles behind such interventions were adopted from high-reliability industries10 such as aviation, which use a more systematic approach to safety than health care does. Peter Pronovost and his team from Johns Hopkins University showed that by following a bundle of safety procedures, they could reduce the incidence of these infections to nearly zero.8 The bundle included steps to follow in central venous catheter insertion, the handling and maintenance of lines, and the prompt removal of unnecessary lines. The National Patient Safety Foundation convened an expert panel to evaluate the progress made in the past 15 years and identify the work being done to assure progress in the next 15 years. Much has been learned about the epidemiology of safety, and while several effective solutions have been developed for some safety issues, their implementation and practice has been inconsistent. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. Early efforts to reduce hospital errors largely focused on hospital safety. In this section we highlight the problems of diagnostic error, outpatient safety, and safety related to health IT because we believe they are especially pressing. In late 1999, the Institute of Medicine published To Err is Human: Building a Safer Health System, a landmark report that brought the nation’s … The high volume of outpatient care and the need for collaboration and communication across the continuum of care increase the potential for errors in outpatient settings. Approaches such as peer-to-peer assessment appear to hold potential for reducing the rates.15, Medication errors have also been found to be one of the most common causes of harm.16 However, effective interventions have been developed. AHRQ has long been the federal leader in supporting multidisciplinary research in this area and needs to continue support for research on emerging safety threats and ongoing harm, because harm rates continue to be too high. 1, No. 7, No. At the organizational level, safety improvement is closely related to good management and the effective implementation of a safety culture.27 A consistent and salient safety culture is a critical determinant of the success of safety interventions, and many organizations now measure their safety culture over time using a validated instrument available from AHRQ, the Hospital Survey on Patient Safety Culture. 6, 25 June 2020 | JAMA Network Open, Vol. A major priority must be to stimulate and support multidisciplinary scientific progress in both understanding the complexity of safety and developing and evaluating interventions. 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