Non-participant direct observation of healthcare processes offers a rich method for understanding safety and performance improvement. As a prospective method for error prediction and modelling, observation can capture a broad range of performance issues that can be related to higher aspects of the system.1–5 It can help identify underlying and recurrent problems6 that may be antecedents to more serious situations.7 It is also a way to understand the complexity of healthcare work that might otherwise be poorly understood or ignored,8 9 how workarounds influence work practices and safety,10 and is of fundamental importance to practitioners wishing to understand resilience in the face of conflicting workplace pressures.11 12 In some cases it will lead to the direct observation of near-misses or precursor events that...
Undeclared sildenafil may interact with nitrates found in some prescription drugs (such as nitroglycerin) and may lower blood pressure to dangerous levels.
When patients and their clinical teams work as partners, there’s a greater likelihood of better outcomes for patients and greater satisfaction for health care providers, many of whom have been suffering high rates of burnout in recent years. Institute for Healthcare Improvement President and CEO, Derek Feeley, chose this theme today to open up the 2017 IHI National Forum on Quality Improvement in Health Care. Feeley addressed nearly 5,500 health care professionals, health leaders, students, patient advocates, and community improvers.
In this essay, Don Berwick considers moral choices physicians face personally, organizationally, and globally and exhorts them to understand that the health of humanity depends on their speaking out against the social injustice of overpricing drugs and services, mass incarceration, and the lack of environmental responsibility.
The IHI/NPSF Lucian Leape Institute, in partnership with the independent research institution NORC at the University of Chicago, recently conducted a public opinion survey of 2,500 US adults representing a cross-section of the population. When asked about patient safety, 41 percent of adults in the United States have some experience with medical error, either directly or indirectly. What lessons does this information offer to our leaders in Washington?
There are 380 pregnancy medical homes in 94 of North Carolina’s 100 counties. According to Community Care of North Carolina, the nonprofit group hired by the state to oversee the program, 94 percent of obstetrical practices that serve the Medicaid population participate in the program.
Today’s doctors face moral choices all the time, including those that challenge their personal honesty, the organizations they work for and the society they live in, says Donald M. Berwick, MD.
December 7, 2017 | Victor Montori argues that it is time for providers to look up from strict protocols and guidelines long enough to get curious about their patients' lives and begin to minimize barriers to better health, not add to them.
This report assesses the state of patient safety in health care, advocating for a total systems approach across the continuum of care and establishment of a culture of safety, and calling for action by government, regulators, health professionals, and others to place higher priority on patient safety improvement and implementation science.
The use of impacted alcohol prep pads could result in adverse events such as infections.
Potential for fading print, with more effect on the expiration dating on the patient tear off portion of the vial label.
Undeclared sildenafil may interact with nitrates found in some prescription drugs (such as nitroglycerin) and may cause a significant drop in blood pressure that may be life threatening.
This document examines best practices for using root cause analysis (RCA) to improve patient safety, and includes guidelines to help health professionals standardize the RCA process and improve the way they investigate medical errors, adverse events, and near misses.
The Institute for Healthcare Improvement (IHI) released guidelines to help standardize the ways in which primary care practitioners activate referrals to specialists and then keep track of the information over time. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era is the work of an expert panel convened to examine current obstacles to a high quality, safe referral process and offer improvement strategies.
The recommendations outlined in this publication are designed to help standardize the ways in which primary care practitioners activate referrals to specialists, and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner.
Biotin in patient samples can cause falsely high or falsely low results, depending on the test. Incorrect test results may lead to inappropriate patient management or misdiagnosis.
Use of the affected product potentially could result in a risk of infection, especially in an immunocompromised patient.
November 21, 2017 | Is "hostage" the right way to describe how patients and family members sometimes feel when they're trying to get the care they need?
The continuing evidence of preventable deaths due to medical error has led to recent calls to improve measurement of safety in hospitals. This need can be adequately addressed by harnessing health information technology.
Anyone who is currently taking Limbrel may be at risk for developing symptoms associated with drug-induced liver injury and/or hypersensitivity pneumonitis. Posted 11/21/2017