A Review of Current State-level Adverse Medical Event Reporting Practices

A Review of Current State-level Adverse Medical Event Reporting Practices PDF Author: Megan Beckett
Publisher: Rand Corporation
ISBN: 0833039911
Category : Medical
Languages : en
Pages : 193

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Book Description
Nearly half of states require or request the reporting of adverse medical events. In 2003, the Institute of Medicine (Patient Safety: Achieving a New Standard of Care) called for the use of consistent standards for medical error reporting. Standardization will facilitate the creation of a national patient safety repository that aggregates data from states and enable policymakers to track trends in adverse events nationally. The Agency for Healthcare Research and Quality (AHRQ) is leading the national Patient Safety Initiative to combat medical errors. This report summarizes the results of an AHRQ sponsored 50-state survey of adverse reporting systems in 2004. It documents the consistency of information that states are collecting as part of their reporting systems, identifies issues related to establishing a national patient safety repository, and presents an action plan to implement a standardized nationwide system elicited from an external advisory panel that was convened explicitly for this purpose.

A Review of Current State-level Adverse Medical Event Reporting Practices

A Review of Current State-level Adverse Medical Event Reporting Practices PDF Author: Megan Beckett
Publisher: Rand Corporation
ISBN: 0833039911
Category : Medical
Languages : en
Pages : 193

Get Book Here

Book Description
Nearly half of states require or request the reporting of adverse medical events. In 2003, the Institute of Medicine (Patient Safety: Achieving a New Standard of Care) called for the use of consistent standards for medical error reporting. Standardization will facilitate the creation of a national patient safety repository that aggregates data from states and enable policymakers to track trends in adverse events nationally. The Agency for Healthcare Research and Quality (AHRQ) is leading the national Patient Safety Initiative to combat medical errors. This report summarizes the results of an AHRQ sponsored 50-state survey of adverse reporting systems in 2004. It documents the consistency of information that states are collecting as part of their reporting systems, identifies issues related to establishing a national patient safety repository, and presents an action plan to implement a standardized nationwide system elicited from an external advisory panel that was convened explicitly for this purpose.

Advances in Patient Safety

Advances in Patient Safety PDF Author: Kerm Henriksen
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 526

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Book Description
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

Improving Diagnosis in Health Care

Improving Diagnosis in Health Care PDF Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473

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Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

To Err Is Human

To Err Is Human PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309068371
Category : Medical
Languages : en
Pages : 312

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Book Description
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies

Improving Healthcare Quality in Europe Characteristics, Effectiveness and Implementation of Different Strategies PDF Author: OECD
Publisher: OECD Publishing
ISBN: 9264805907
Category :
Languages : en
Pages : 447

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Book Description
This volume, developed by the Observatory together with OECD, provides an overall conceptual framework for understanding and applying strategies aimed at improving quality of care. Crucially, it summarizes available evidence on different quality strategies and provides recommendations for their implementation. This book is intended to help policy-makers to understand concepts of quality and to support them to evaluate single strategies and combinations of strategies.

Patient Safety

Patient Safety PDF Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309090776
Category : Medical
Languages : en
Pages : 551

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Book Description
Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.

Making Healthcare Safe

Making Healthcare Safe PDF Author: Lucian L. Leape
Publisher: Springer Nature
ISBN: 3030711234
Category : Medical
Languages : en
Pages : 450

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Book Description
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.

Cognitive Informatics

Cognitive Informatics PDF Author: Kai Zheng
Publisher: Springer
ISBN: 3030169162
Category : Medical
Languages : en
Pages : 321

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Book Description
This timely book addresses gaps in the understanding of how health information technology (IT) impacts on clinical workflows and how the effective implementation of these workflows are central to the safe and effective delivery of care to patients. It features clearly structured chapters covering a range of topics, including aspects of clinical workflows relevant to both practitioners and patients, tools for recording clinical workflow data techniques for potentially redesigning health IT enabled care coordination. Cognitive Informatics: Reengineering Clinical Workflow for More Efficient and Safer Care enables readers to develop a deeper understanding of clinical workflows and how these can potentially be modified to facilitate greater efficiency and safety in care provision, providing a valuable resource for both biomedical and health informatics professionals and trainees.

Quality and Safety in Anesthesia and Perioperative Care

Quality and Safety in Anesthesia and Perioperative Care PDF Author: Keith J. Ruskin
Publisher: Oxford University Press
ISBN: 0199366144
Category : Medical
Languages : en
Pages : 321

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Book Description
Quality and Safety in Anesthesia and Perioperative Care offers practical suggestions for improving quality of care and patient safety in the perioperative setting. Chapters are organized into sections on clinical foundations and practical applications, and emphasize strategies that support reform at all levels, from operating room practices to institutional procedures. Written by leading experts in their fields, chapters are based on accepted safety, human performance, and quality management science and they illustrate the benefits of collaboration between medical professionals and human factors experts. The book highlights concepts such as situation awareness, staff resource management, threat and error management, checklists, explicit practices for monitoring, and safety culture. Quality and Safety in Anesthesia and Perioperative Care is a must-have resource for those preparing for the quality and safety questions on the American Board of Anesthesiology certification examinations, as well as clinicians and trainees in all practice settings.

Making Health Care Safer

Making Health Care Safer PDF Author:
Publisher: Department of Health and Human Services
ISBN:
Category : Medical
Languages : en
Pages : 744

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Book Description
"This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety"--P. v.