Applied Strategies for Improving Patient Safety: A Comprehensive Process To Improve Care in Rural and Frontier Communities

CONTEXT: Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. PURPOSE: To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN. Findings: Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors. CONCLUSIONS: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.     

Assuring Rural Hospital Patient Safety: What Should Be the Priorities?

CONTEXT: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. PURPOSE: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. METHODS: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. FINDINGS: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. CONCLUSIONS: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.     

The challenges to transparency in reporting medical errors

In an ideal health care environment, physicians and health care organizations would acknowledge and factually report all medical errors and "near misses" in an effort to improve future patient safety by better identifying systemic safety lapses. Truth must permeate the health care system to achieve the goal of transparency. The Institute of Medicine has estimated that 44,000 to 98,000 patients die each year as a result of medical errors. Improving the reporting of medical errors and near misses is essential for better prevention of medical errors and thus increasing patient safety. Higher rates of reporting can permit identification of the root causes of errors and create improved processes that can significantly reduce errors in future patient care. Multiple barriers exist with respect to reporting medical errors, despite the ethical and various professional, regulatory, and legislative expectations and requirements generating this obligation. As long as physicians perceive that they are at risk for sanctions, malpractice claims, and unpredictable compensation of injured patients as determined by the United States' tort law system, legislative or regulative reform is unlikely to affect the underreporting of medical errors, and patient safety cannot benefit from the lessons derived from past medical errors and near misses. A new infrastructure for creating patient safety systems, as identified in the Patient Safety and Quality Improvement Act of 2005 is needed. A patient compensation system guided by an administrative health court that includes some form of no-fault insurance must be studied to identify benefits and risks. Most urgent is the development of a reporting system for medical errors and near misses that is transparent and effectively recognizes the legitimate concerns of physicians and health care providers and improves patient safety.     

Safety risks in the ambulatory setting

Over the past decade, the focus of safety implementation has been on hospital settings, and most research on patient safety has examined hospital care. Yet, each year, 300 Americans are seen in ambulatory settings for every 1 person admitted to a hospital, and research shows that errors in ambulatory settings can be just as devastating as those in hospitals, and, as in the hospital setting, ambulatory errors or events often trigger legal action. The American Medical Association's report summarizing and compiling the past decade's research identifies 3 general gaps in the current research that impede safety analysis and 6 errors that are most common in ambulatory care that warrant attention. As new models of care emerge with an increased focus on continuity across care settings, there are also nascent opportunities for risk managers to analyze and evaluate ambulatory safety, implement strategies, and develop and test tools that could result in safer patient outcomes.     

Rural Hospital Patient Safety Systems Implementation in Two States

CONTEXT AND PURPOSE: With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals. METHODS: Survey of all acute care hospitals in Utah and Missouri at 2 points in time (2002 and 2004). Factor analysis was used to develop 7 latent variables to summarize the data, comparing rural and urban hospitals at each point in time and on change between the 2 survey times. FINDINGS: On 3 of the 7 latent variables, there was a statistically significant difference between rural and urban hospitals at the first survey, with rural hospitals indicating lower levels of implementation. The differences remained present on 2 of those latent variables at the second survey. In both cases, 1 of those variables was computerized physician order entry (CPOE) systems. Rural hospitals reported more improvement in systems implementation between the 2 survey times, with the difference statistically significant on 1 of the 7 latent variables; the greatest improvement was in implementation of "root cause analysis." CONCLUSIONS: Adoption of patient safety systems overall is low. Although rates of adoption among rural versus urban hospitals appear lower, most differences are not statistically significant; the gap between rural and urban hospitals relative to quality measures is narrowing. Change in rural and urban hospitals is in the right direction, with the rate of change higher in rural hospitals for many systems.     

Hospital progress in reducing error: the impact of external interventions

Millions of Americans are harmed each year from medical errors. New patient safety standards, voluntary and mandatory error reporting, and increased public awareness have been interventions to improve patient safety. The author performed a survey of 145 hospital administrators from 48 states using the Baldrige 2006 Heath Care Criteria for Performance Excellence to investigate quality improvement efforts to reduce medical errors. Hospital administrators reported significant progress in implementing quality improvement processes that have reduced medical errors. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation was an effective intervention to drive efforts to reduce medical errors, whereas state medical error reporting and public awareness were not effective interventions.     

Calendar of Meetings

Medical errors and patient safety are urgent healthcare management challenges. To date, not enough has occurred to provide a systematic organizational design framework for reducing medical errors and improving patient safety. The authors offer such a framework by integrating multiple organizational factors and using well-accepted organization theory, citing relevant empirical research studies of medical errors and patient safety to support specific organizational factors. They discuss organizational design implications and recommendations for healthcare executives.     

Designing healthcare organizations to reduce medical errors and enhance patient safety

Medical errors and patient safety are urgent healthcare management challenges. To date, not enough has occurred to provide a systematic organizational design framework for reducing medical errors and improving patient safety. The authors offer such a framework by integrating multiple organizational factors and using well-accepted organization theory, citing relevant empirical research studies of medical errors and patient safety to support specific organizational factors. They discuss organizational design implications and recommendations for healthcare executives.     

Patient safety attitudes and behaviors of graduating medical students

As North American medical schools reformulate curricula in response to public calls for better patient safety, surprisingly little research is available to explain and improve the translation of medical students' knowledge and attitudes into desirable patient safety behaviors in the clinical setting. A total of 139 fourth-year medical students at Virginia Commonwealth University, School of Medicine, 96% of the 2010 graduating class, completed the Attitudes toward Patient Safety Questionnaire and a self-report of safety behaviors. The students were exposed to informal discussions of patient safety concepts but received no formal patient safety curriculum. Most students recognized errors and responded with attitudes supportive of patient safety but desired behaviors were less common. In particular, errors went unreported, owing, in part, to the relationships of power and social influence undergirding the traditional authority gradient in the culture of medicine. A deeper understanding of patient safety attitudes, behavior, and medical culture is required to better inform instructional design decisions that influence desired patient safety behaviors and improve patient care.     

The ethical leadership challenge: creating a culture of patient- and family-centered care in the hospital setting

The growing number of medical errors and resulting preventable deaths in hospitals presents an ethical dilemma that must be addressed by health care leaders and managers. These medical errors and deaths raise questions about safety and quality issues resulting in rising public mistrust and patient dissatisfaction. Many of these medical errors and deaths could have been avoided by including the patient and family in the care. The ethical challenge for leadership is creating a culture of patient- and family-centered care as a means to improve quality, safety, patient satisfaction, and public trust. This article addresses ways to improve safety, quality, patient satisfaction, and cost and thereby reduce medical errors and deaths by implementing a patient- and family-centered care culture. The first critical step for improvement is for hospital leaders and managers to answer the ethical call to create a culture centered on patient- and family-centered care in the hospital setting.     

新建综合性医院医护人员患者安全文化研究

目的了解某新建综合性医院医护人员患者安全文化现状,寻找薄弱环节和潜在隐患,为患者安全文化水平持续改进与不断提升提供参考依据。方法采用美国医疗服务质量和研究组织通行的患者安全问卷调查法,计算正性回答率,获得该医院患者安全文化数据,和AHRQ同类医院正性反应率进行比较。结果该医院部门/区域安全等级评分正性反应率为75.5%。差错的反馈和交流、组织文化-不断改善、科室内部团队合作3个维度为患者安全优势领域。对差错的非惩罚性处理、人员配备、不良事件上报频率、科室间团队合作4个维度,为患者安全待改进领域;正性反应率最低的维度及与AHRQ差值最大的维度差错的非惩罚性处理、不良事件报告频率,提示为制约新建医院患者安全文化建设的关键环节及影响因素。结论建立公正文化,可促进不良事件上报,提升患者安全水平。     

哈尔滨市医务人员患者安全文化认知状况调查

目的对医务人员患者安全文化认知状况进行调研,为提升其患者安全文化认知水平提供参考。方法对哈尔滨市4所三级公立医院372名医务人员发放中文版医院患者安全文化调查问卷（HSOPSC）。所得数据利用EpiData 3.1软件及SPSS 22.0软件进行整理分析。结果72.58%的医务人员在过去12个月内从未上报不良事件。“组织学习与改进”“科室内团结合作”正性应答率较高。待改进维度为“事件报告频率”“人力资源配置”“对差错的非惩罚性反应”。结论医疗机构需提升医务人员患者安全文化认知,营造正向的患者安全文化氛围,以保障患者安全目标的实现。     

Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative

BACKGROUND: We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy. RESULTS: Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data. CONCLUSION: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.     

Patient safety: solutions in managed care organizations?

Despite the growing acknowledgment of the necessity for patient safety initiatives to address medical errors, the role of managed care organizations (MCOs) in these programs has only recently been challenged. Managed care quality improvement programs have mainly focused upon pay-for-performance initiatives, largely ignoring specific patient safety efforts. To effectively reduce medical errors, MCOs must leverage their unique positions to influence and educate both providers and consumers. This article describes MCOs' self-implemented barriers to quality improvement, and early initiatives by MCOs to encourage safe practices, including pay-for-performance. An approach for MCOs to facilitate progress and inspire a culture of patient safety is discussed. Avenues for strengthening the organizational and technological infrastructure of the health care system from a managed care perspective are examined, and strategies for implementing best practices within the constraints of managed care are explored. System-wide solutions that address the critical areas of culture, infrastructure, and best practices are necessary to continue to make significant strides in reducing medical errors and prioritizing patient safety.     

用药闭环管理与医疗安全

目的通过医院信息化建设,提高医疗质量,减少用药差错,保证患者安全。方法从患者安全角度出发,分析用药流程,提出用药闭环管理需求,实现用药闭环信息化。结果实现了患者识别的闭环;护士执行的闭环;医嘱开立的闭环;药品准备的闭环;用药记录的闭环。2015年,无用药错误的不良事件发生。结论药品的闭环管理有效降低了用药错误的发生,保证患者安全。     

Care transitions from inpatient to outpatient settings: ongoing challenges and emerging best practices

Care transitions occur every time a patient changes levels of service, location, or with each shift change or transfer of care. The complexities involved in transitions of care make these time periods particularly susceptible to medical errors, placing patients at risk. Improving care transitions affects all patients in all settings, and has the potential to reduce adverse events, improve quality of care, and produce medical cost savings. This article is a focused review of transitions in care from the inpatient to ambulatory care settings. Underlying challenges and sources of errors are identified, and possible solutions and interventions are explored. Specific challenges to the pediatric population are also examined in detail.     

1例用药近似错误事件的根因分析

通过根本原因分析法,对1例潜在严重后果的手术患者止血药物近似错误案例进行剖析,探讨医嘱管理、相似药品、沟通不良、药物相关知识缺乏、惯性思维等对安全用药的影响。口头指示不清或不明可能导致用药错误,口头医嘱存在较高风险;医护人员用药知识不丰富是医嘱错误常见原因之一;系统不完善可能导致用药差错。确保用药安全需要优化制度流程,加强临床医务工作者的有效沟通与协作,强化医务人员角色功能定位以及完善系统等。