PATIENT SAFETY PRIMERS
COVID-19: Team and Human Factors to Improve Safety
NEW
… Culture of Safety … Simulators … Human Factors Engineering … Quality Improvement Strategies … … stress on local healthcare systems and associated workforces. Healthcare is a fundamentally human endeavor; its … the stigma associated with help-seeking by establishing infrastructure and readily available opportunities for peer …
PATIENT SAFETY PRIMERS
Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults
… Nurse Staffing Ratios … Policies and Operations … Telemedicine … Published: April 21, 2020 … 7 In addition, most nursing homes have relatively little information technology, 8 few infection control supplies, and … licensed nurses to provide direct care. 10 The Patient Safety Problems Infection Control and Prevention: COVID-19 …
PATIENT SAFETY PRIMERS
Discharge Planning and Transitions of Care
… … Clinical Pharmacist Involvement … Background Transitions of care refer to the movement of patients between … be challenging as patients and families become responsible for care coordination. Hospital discharges are complicated … pharmacists can play a crucial role in medication safety during transitions of care through medication …
PATIENT SAFETY PRIMERS
Improving Patient Safety and Team Communication through Daily Huddles
Communication failures among healthcare personnel are significant contributors to medical errors and patient harm. This new primer provides an overview of “huddles”, a technique to enhance team communication that has been shown to reduce the risk for harm. The “Huddles” primer provides a definition along with when and how huddles might be used to improve patient safety.
PATIENT SAFETY PRIMERS
Clinical Decision Support Systems
Clinical decision support systems provide information or recommendations to help clinicians make safe and evidence-based decisions. The use and sophistication of these systems have grown markedly over the past decade, due to widespread implementation of electronic health records and advances in clinical informatics.
PATIENT SAFETY PRIMERS
Opioid Safety
… Approaches … Background As medical knowledge evolves, the balance of harms and benefits for specific medications … evolves as well, and therapies initially thought to be effective and low risk ultimately may be judged to … continued to increase, the death toll rose as well. According to data from the Centers for Disease Control and …
PATIENT SAFETY PRIMERS
Maternal Safety
Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.
PATIENT SAFETY PRIMERS
Burnout
… Human Factors Engineering … Burnout among health care professionals … satisfaction, and poorer safety and quality ratings . The reported prevalence of burnout among health care … of Medicine advocates organizing intervention targets according to Maslow's Hierarchy of Needs , addressing basics …
PATIENT SAFETY PRIMERS
Medication Administration Errors
Medication administration errors are a persistent safety problem. Increasing the safety of medication administration requires a multifaceted system-level approach that spans all phases of primary, specialty, inpatient, and community-based care.
PATIENT SAFETY PRIMERS
Surgical Site Infections
Infections after surgery are common and frequently lead to hospital readmission and other adverse consequences for patients. Recent programs, including several led by the Agency for Healthcare Research and Quality, have demonstrated how hospitals can successfully prevent these infections.
PATIENT SAFETY PRIMERS
The Pharmacist's Role in Medication Safety
Pharmacists in all settings play a crucial role in medication safety.
PATIENT SAFETY PRIMERS
Patient Safety 101
… Error Reporting and Analysis … Communication between Providers … Just … … Human Factors Engineering … The History of the Patient Safety Movement The concept that patients could be harmed while receiving medical care has been known for thousands of years, since Hippocrates coined the phrase …
PATIENT SAFETY PRIMERS
Electronic Health Records
The widespread implementation of electronic health records has caused a sea change in health care and in medical practice. The digitization of health care data has had some positive effects on patient safety, but it has also created new patient safety concerns.
PATIENT SAFETY PRIMERS
Individual Clinician Performance Issues
Most safety improvement efforts justifiably emphasize system performance. A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.
PATIENT SAFETY PRIMERS
Failure to Rescue
Failure to rescue is both a concept and a measure of hospital quality and safety. The concept captures the idea that systems should be able to rapidly identify and treat complications when they occur, while the measure has been defined as the inability to prevent death after a complication develops.
PATIENT SAFETY PRIMERS
Falls
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
PATIENT SAFETY PRIMERS
Long-term Care and Patient Safety
A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that more than 20% of patients in these settings experience an adverse event during their stay.
PATIENT SAFETY PRIMERS
Health Literacy
… Health literacy is defined as an individual's ability to find, process, and comprehend the basic health information necessary to act on medical … press conference with the Institute of Medicine report. According to the Institute of Medicine, health literacy is a …
PATIENT SAFETY PRIMERS
Measurement of Patient Safety
… Error Reporting and Analysis … Background The 1999 Institute of Medicine To … in medicine and led to the creation of the modern patient safety field. Yet little of the material in To Err Is Human … every year due to preventable harm) was based were performed many years before the report was issued. The reason …
PATIENT SAFETY PRIMERS
Debriefing for Clinical Learning
Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.
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