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Showing results for tags 'USA'.
Found 658 results
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Content ArticleProven patient safety solutions such as the World Health Organization’s Surgical Safety Checklist can be difficult to implement at scale. This article looks at a voluntary initiative launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that implemented the checklist by 2017 had higher levels of CEO and physician participation than comparison hospitals, and engaged more in activities such as in-person meetings and teamwork skills trainings. The authors suggest three considerations for hospital, state and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others) Offering a variety of program activities—both lower-touch and higher-touch—over the duration of the program allows more hospital and individual participation Change takes time and resources
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Content ArticleThis article explores political barriers to integrated care, arguing that improving the US healthcare system requires the pursuit of three aims: improving the experience of care, improving the health of populations and reducing per capita costs of health care.
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Content ArticleThis article in The BMJ examines the case for vaccinating children under five against Covid, following the US recently recommending that children aged six months to five years should receive Covid-19 vaccines. It looks at the risks and benefits of vaccination for young children, citing recent Moderna and Pfizer trials. It highlights that children are more likely than adults to experience asymptomatic Covid-19 or very mild illness, and are much less likely to have severe disease requiring hospital admission. But for children with underlying health conditions, such as long term neurological disease, vaccination may be beneficial in preventing severe disease.
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Content ArticleIn this episode of the Driving Insights to Action podcast, patient safety advocates Soojin Jun and Sue Sheridan talk about the role of the World Health Organization's Global Patient Safety Action Plan in helping reduce medication errors in healthcare. They also share their personal experiences of family members' deaths as a result of avoidable harm in healthcare.
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Content ArticleThis landmark report from the Leapfrog Group, an independent national healthcare safety watchdog in the US, is the result of an intensive year-long effort bringing together the nation’s leading experts on diagnostic excellence, including physicians, nurses, patients, health plans, and employers. Together, the multi-stakeholder group reviewed the evidence and identified 29 evidence-based actions hospitals can implement now to protect patients from harm or death due to diagnostic errors. Diagnostic errors contribute to 40,000-80,000 deaths a year, with over 250,000 Americans experiencing a diagnostic error in hospitals. This includes delayed, wrong, and missed diagnoses, and those that are not effectively communicated to the patient.
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Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
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Content ArticleThe Birth Injury Help Center is a US-based online resource centre that provides information on birth injuries, as well pregnancy and childbirth. This article provides information for pregnant women about foods, drinks, medications and activities to avoid during pregnancy.
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Content ArticleThe Peer Network for Advancing Equity through Quality and Safety is a year-long program offered by the Center for Health Equity at the American Medical Association (AMA) in collaboration with the Brigham & Women’s Hospital (BWH) and The Joint Commission (TJC). It is designed to help health systems apply an equity lens to all aspects of quality and safety practices and improve health outcomes for historically marginalised populations. This article covers the program's strategic plan, goals and activities and includes embedded videos containing an introduction to the program and a simulated case review.
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Content Article
The Patient Revolution: How we revolt guide (June 2022)
Patient-Safety-Learning posted an article in Culture
This guide from The Patient Revolution aims to help healthcare activists contribute to an international movement for care. It summarises the foundations of The Patient Revolution's collective work towards the goal of careful and kind care for all. Underpinning these foundations is the idea that industrialised healthcare undermines compassionate, individualised care and costs more, both in terms of patient safety and financial cost. The guide provides tools and principles to help activists transform the way care is offered and promote genuine patient-healthcare collaboration. -
Content ArticleThe Patient-Centered Outcomes Research Institute (PCORI) is an independent, non-profit research organisation that seeks to empower patients and others with actionable information about their health and healthcare choices. It funds comparative clinical effectiveness research (CER), which compares two or more medical treatments, services, or health practices to help patients and other stakeholders make better informed decisions. The PCORI Strategic Plan provides a roadmap for its activities in the years ahead as they pursue their vision and mission. Developed with extensive stakeholder input, the Plan articulates a refined focus on generating patient-centered evidence that has the greatest positive impact on health outcomes.
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Content ArticleAfter the US Food and Drug Administration (FDA) first warned in 2008 of serious complications associated with transvaginal mesh, thousands of lawsuits have been filed, most of which were compiled into seven federal multidistrict litigation cases against the major manufacturers. This blog by Meghann Cuniff for Forbes Advisor provides an update on the progress of these law suits. It also advises on how to file a vaginal mesh lawsuit and joining a class action lawsuit.
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Content ArticleThis study in BMJ Open Quality examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement, in an effort to measure the transition to high reliability. It reports on the development of two scales (trust in team members and trust in leadership) in a US children’s hospital which was seeking to assess progressive movement towards a ‘culture of safety'. The scales were designed to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities.
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Content ArticleMoral injury is a specific kind of trauma that can happen when when people face situations that deeply violate their conscience or threaten their core values. This blog for Scientific American looks at the experience of ER doctor Torree McGowan when the Delta wave of Covid-19 hit the central Oregon region where she works. It examines the impact that moral injury has had on her mental health and her relationship with patients. The author looks at how Covid-19 hugely increased the incidence of moral injury as people in frontline roles faced ethically wrenching dilemmas every day. The growing realisation that moral injury is a separate diagnosis to other conditions such as PTSD and depression is resulting in a wider range of treatments and trauma therapies. Many of these treatments encourage people to face moral conflicts head-on rather than blotting them out or explaining them away, and they emphasize the importance of community support in long-term recovery.
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Content ArticlePeripherally inserted central catheters (PICCs) are medical devices often used for medium-to-long-term intravenous therapy, but they are often associated with morbid and potentially lethal complications. This multi-centre study in the journal Plos One aimed to identify barriers and facilitators to implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. The authors found that structured quality improvement (QI) efforts led to sustained PICC appropriateness and improved patient safety. These interventions included a multidisciplinary vascular access committee, clear targets, local champions and support from an online education toolkit.
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Content ArticleIn this episode of 'Better Never Stops', Virginia Mason Institute Senior Partner Melissa Lin interviews Dana Nelson-Peterson, Vice President of Nursing Operations at Virginia Mason Franciscan Health, who shares what happens when you trust a management system and improvement process to solve your toughest challenges. Dana shares her story of leading a critical part of Virginia Mason’s Covid response.
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Content ArticleThis article describes how a radiology group in Arizona allegedly missed dozens of breast malignancies, some of which were obviously cancer. Breast surgeon Dr Beth Dupree and a team of expert radiologists identified 25 missed cancer diagnoses that required either surgery, chemotherapy, radiation or a mastectomy at Northern Arizona Healthcare between 2016 and 2018. The team felt that there was a high chance of the number of women with missed cancers being higher than those uncovered by the review, but their request to expand the investigation did not go ahead.
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Content ArticleDrugwatch is a US consumer advocacy organisation that works with certified medical and legal experts to educate the public on dangerous drugs and medical devices and to empower consumers to assert their legal rights. In this article, Terry Turner, writer for Drugwatch, examines the history of the medical tech company C.R. Bard, which specialises in vascular, urology, surgery and oncology devices. Bard manufactures thousands of medical devices and sells them worldwide. The article looks at how the company was established and then examines several legal issues Bard has faced, including criminal charges stemming from medical fraud and accusations of selling defective devices that have killed patients or caused serious complications. The author looks at criminal charges concerning heart catheters to which Bard pleaded guilty. They also highlight problems with Bard's transvaginal and hernia mesh products and inferior vena cava (IVC) filters—devices designed to catch blood clots before they reach the lungs or the heart.
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Content ArticleThis webpage provides information about patient rights and responsibilities while under the care of John Hopkin's Children's Center. It includes the following resources and guides: Patient and family handbook Preparation Pain management Your child’s care team Rooms Meals Visitation Patient safety Parent and family journal
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Content Article100 days into her role as interim Chief Inspector at the Healthcare Safety Investigation Branch (HSIB), Dr Rosie Pennyworth reflects on her focus so far. She talks about spending time developing close relationships with HSIB staff to ensure she is able to effectively guide them through the transformation process as the organisation becomes the Health Services Safety Investigations Body (HSSIB). She also talks about keeping patients and families at the centre of future strategy and developing an international network with counterpart organisations in the US, Sweden and Norway.
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Content ArticleIn this blog, Gurpreet Kaur, who had to use a wheelchair for five years due to the severity of her endometriosis, talks about her firsthand experience of gender bias in pain management. She recalls sexist and inappropriate comments made to her by male healthcare professionals, describing how they belittled her pain and treated her as a 'hysterical woman'. She also highlights that research clearly demonstrates that women of color are more disproportionately affected by dismissals of their pain.
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Content ArticleThis report by the US non-profit organisation the Emergency Care Research Institute (ECRI) was commissioned by the US Food and Drug Administration (FDA) to determine the safety profile of polypropylene (PP) mesh used in a variety of surgical procedures. ECRI performed a comprehensive literature search and systematic review to identify the current state of knowledge about how patients' bodies respond to PP mesh.
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Content Article
In this blog, Kath Sansom, founder of the Sling the Mesh campaign, unpacks the findings of a medical device performance study into polypropylene mesh published by the Emergency Care Research Institute (ECRI) in the US. The document highlights significant gaps in evidence about the risk of complications associated with polypropylene (PP) surgical mesh. -
Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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Content ArticleAccording to a recent research study published in the journal Annals of Internal Medicine, over a million people with diabetes in the US rationed their insulin in the past year. When people with diabetes ration their insulin, either by taking less than they need or skipping doses, it poses a serious safety risk and has a negative impact on their long-term health. This article highlights that the main cause of insulin rationing is the high cost of insulin in the US, with pharmaceutical companies increasing prices annually even though the product remains the same. It outlines the main issues caused by insulin rationing and looks at the need for reform to ensure that all Americans with diabetes are able to access adequate insulin. The author speaks to Stephanie Arceneaux who has had type 1 diabetes for 30 years. Stephanie describes her experiences of deciding whether or not to eat and therefore use more insulin, and of having to ration blood glucose test strips.
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Content Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.
