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A recent report on patient safety from the Institute of Medicine (IOM) of the National Academies, Crossing the Quality Chasm: A New Health System for the 21st Century, criticizes the US health care delivery system, finding it to be poorly designed and inept at meeting the needs of patients.
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While the Institute of Medicine made recommendations to Congress for investigating medical errors and improving patient safety, the reality was that extensive foundation building needed to occur before meaningful improvements could be put into action.
PATIENT SAFETY A 1999 Institute of Medicine report brought medical errors to the forefront of healthcare and the American public (Kohn, Corrigan, & Donaldson, 1999).
While the IOM made recommendations to Congress for investigating medical errors and improving patient safety, the reality was that extensive foundation building needed to occur before meaningful improvements could be put into action.
Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety.
What did the IOM Health Professions Education report highlight as a concern for patient safety? The IOM Health Professions Education report (2004) highlighted the education of health disciplines in silos as a major concern in patient safety and endorsed five recommendations.
The IOM report called for a 50% reduction in medical errors over 5 years. Its goal was to break the cycle of inaction regarding medical errors by advocating a comprehensive approach to improving patient safety. This IOM report received tremendous attention from both the public and the healthcare industry.
The Institute of Medicine (IOM) released their landmark report, To Err Is Human, in 1999 and reported that as many as 98,000 people die in hospitals every year as a result of preventable medical errors.
The IOM describes evidence-based practice as the integration of research evidence, clinical expertise, and patient values in making decisions about the care of individual patients. Each of these sources may be contributing factors relevant to decision making regarding patient care.
To Err Is Human asserts that the problem is not bad people in health care--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.
On November 29, 1999, the Institute of Medicine (IOM) released a report called To Err is Human: Building a Safer Health System. The IOM released the report before the intended date because it had been leaked, and one of the major news networks was planning to run a story on the evening news.
Tracking The Changing Safety Net The 2000 IOM report found that the federal government lacked any comprehensive, coordinated ability to track and monitor the changing status of America's health care safety net and its success in meeting the needs of our most vulnerable populations.
What has been the historical importance of the Institute of Medicine (IOM) reports since 1999? 1. They stimulated the development of strategies that will improve quality of care.
Which quality issues were found in the Institute of Medicine (IOM) study, To Err is Human: Building a Safer Health System? Many errors are preventable. Data from the IOM study concluded that up to 98,000 patients die each year from preventable medical errors.
One of the most commonly used frameworks comes from the Institute of Medicine (IOM), which has articulated six aims of health care that many consider to be domains of quality, broadly defined. The IOM says health care should be safe, effective, timely, patient-centered, efficient and equitable.
Its follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), introduced the IOM Six Aims for Improvement: care that is safe, timely, effective, efficient, equitable and patient-centered (STEEEP).
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In response to the April 2003 Institute of Medicine (IOM) report titled Health Professions Education: A Bridge to Quality, the author assesses the report in light of the present education of professional nurses.
Objectives: We examined the effectiveness of an innovative mobile mock operating room (MMOR) configuration to support realistic interdisciplinary operating room team training implemented at the point of care. Methods: The MMOR, created and used to support the System for Teamwork Effectiveness and Patient Safety (STEPS) training program, included a portable high-fidelity, computerized mannequin; an inanimate surgical procedure model; software for simulating mannequin responses; and a computer-based video recording system. Evaluation was based on direct experience with the MMOR and participants’ responses to a questionnaire. Results: Participants perceived the MMOR as a realistic training environment. Feasibility and effectiveness were further supported by the research team experiences. Conclusion: The MMOR contributes to quality training at the point of care. Results suggest that our MMOR model may be useful for supporting simulation-based training in other high-risk settings where effective team functioning is particularly important (e.g., emergency room, intensive care unit).
To implement a laboratory session into the first-year pharmacy curriculum that would provide active-learning experiences in the recognition, resolution, and prevention of medication errors. Students participated in medication error-prone prescription processing and counseling simulations, role-played communication strategies after a medication error occurred, and discussed an introductory pharmacy practice experience focused on prescription processing and prevention of medication errors. Students completed an assessment prior to and after completion of the laboratory on their knowledge of and confidence in identifying medication errors. Students' knowledge and awareness of medication errors improved as did confidence in their ability to (1) recognize and avoid errors, (2) utilize methods to prevent errors, (3) communicate about errors with involved parties, and (4) select and report medication errors on an appropriate form. Students' awareness of the pharmacist's role in medication error reduction improved and confidence in their ability to recognize, prevent, and communicate medication errors increased.
Inter-professional learning (IPL) and inter-professional practice (IPP) are thought to be critical determinants of effective care, improved quality and safety and enhanced provider morale, yet few empirical studies have demonstrated this. Whole-of-system research is even less prevalent. We aim to provide a four year, multi-method, multi-collaborator action research program of IPL and IPP in defined, bounded health and education systems located in the Australian Capital Territory (ACT). The project is funded by the Australian Research Council under its industry Linkage Program. The program of research will examine in four inter-related, prospective studies, progress with IPL and IPP across tertiary education providers, professional education, regulatory and registration bodies, the ACT health system's streams of care activities and teams, units and wards of the provider facilities of the ACT health system. One key focus will be on push-pull mechanisms, ie, how the education sector creates student-enabled IPP and the health sector demands IPL-oriented practitioners. The studies will examine four research aims and meet 20 research project objectives in a comprehensive evaluation of ongoing progress with IPL and IPP. IPP and IPL are said to be cornerstones of health system reforms. We will measure progress across an entire health system and the clinical and professional education systems that feed into it. The value of multi-methods, partnership research and a bi-directional push-pull model of IPL and IPP will be tested. Widespread dissemination of results to practitioners, policymakers, managers and researchers will be a key project goal.
Abstract: Homi K. Bhabha is a post-colonial and cultural theorist who describes the emergence of new cultural forms from multiculturalism. When health profession students enculturated into their profession discuss patient care in an interprofessional group, their unilateral view is challenged. The students are in that ambiguous area, or Third Space, where statements of their profession’s view of the patient enmesh and an interprofessional identity begins to form. The lessons learned from others ways of assessing and treating a patient, seen through the lens of hybridity allow for the development of a richer, interprofessional identity. This manuscript will seek out the ways Bhabha’s views of inbetweenness enhance understanding of the student’s development of an interprofessional viewpoint or identity, and deepen the author’s developing framework of an Interprofessional Community of Practice. Keywords: interprofessional education; third space; hybridity; interprofessional identity
Using simulation to teach pharmacy practice skills may result in knowledge that is transferable to patient care. Key areas in which simulation is being used in pharmacy education include therapeutics, communication, physical assessment, patient safety, and populations to which students may have infrequent exposure. Enhancing interprofessional healthcare team dynamics and the skills of practicing healthcare professionals are other practical applications for simulation education. Educators should continue to be creative in the incorporation of simulation into pharmacy education and conduct more studies on the impact of simulation education on patient care to demonstrate the efficacy of this teaching modality.
Nursing Informatics (NI) divided into basic computer competence and advanced nursing informatics competence. The purpose of this paper is to provide and highlight the information about Nursing Informatics (NI) and the effect on patients care and outcome. Health professionals should use informatics to communicate, manage knowledge, mitigate error, and support decision making using information technology. Organizations and, authors recommended NI for analyzing, formalizing and modeling the collection, management, processing and analysis of data to build information and knowledge that will inform decisions regarding patient care, which included more than one view.
Because there are so many barriers, significant reform is a relatively rare occurrence. Yet it does happen and there are some important examples of major health care reforms. There are a number of lessons to be learned from the successful enactment of the Medicare and Medicaid programs that appear relevant to current and future reform efforts. First, a necessary condition for achieving significant reform is the existence of large and sufficiently enduring social forces sufficient to disrupt legislative and policy stasis and drive the necessary political solutions. Second, public sentiment and electoral "mandates" might be necessary to significant reform, but they are not sufficient. Third, assuming the theoretical capacity to manage the constellation of systemic, economic, legal, cultural and legislative barriers, there remains a political "tipping point" that must be crossed and translated into a Congressional super-majority in order to enact significant nationwide reform.
Setting a Direction. In early 2000, just 60 days after the IOM report was published, the Federal Government, through an AHRQ-led task force, released Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.
Given the central role that nurses serve in patient care and the likelihood that they are among the first health care professionals to recognize errors and prevent harm to patients, the Agency teamed with the Robert Wood Johnson Foundation to develop and distribute a handbook for nurses entitled Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Even though working conditions may be less than optimal and the needs of patients are quite diverse, the opportunities for patient safety and quality improvement are clearly addressed. More than 22,000 copies of the three-volume handbook have been distributed to nursing schools and clinicians in the field.
AHRQ released Advances in Patient Safety: From Research to Implementation as a way to share the progress occurring in the first half of the decade. The four-volume publication, comprising 140 articles, sought to bridge the gap between the research underway and its integration into practice. The compendium covered a wide range of research paradigms, clinical settings, patient populations, reporting systems, measurement and taxonomy issues, tools and technology, implementation challenges, safety culture, and organizational considerations. The volumes helped fuel efforts to improve patient safety and provided a measure of progress. More importantly, they also provided a sense of remaining challenges.
AHRQ WebM&M serves as a free, online journal and forum for the examination of a variety of patient safety and quality issues. It features analysis of medical error cases by recognized experts and provides interactive learning modules for health care professionals, clinicians, administrators, patient safety officers, and trainees. Since its launch, AHRQ WebM&M has grown in popularity and continues to be one of AHRQ's most frequently visited Web sites.
In response to the need to expand the patient safety knowledge and skills of midlevel professionals responsible for investigating medical errors and initiating improvements, AHRQ partnered with the Department of Veterans Affairs' National Center for Patient Safety and began the first of four 9-mont h Patient Safety Improvement Corps (PSIC) training programs. Participants received training on tools and topics including analyzing root causes, analyzing health care failure modes and effects, applying human factors principles, assessing patient safety culture, and making a business case for patient safety. By the program's end, teams had been trained in every State, as well as the District of Columbia and Puerto Rico. Feedback the Agency received that PSIC graduates were, in turn, training their own personnel in patient safety principles acquired from the program provided evidence that this program represented a significant step in disseminating patient safety knowledge throughout the country.
Data indicate that health care-associated infections (HAIs) are the most common serious complication of hospital care, striking nearly 2 million U.S. hospital patients, resulting in an estimated 99,000 deaths, and costing the health care system up to $20 billion each year, according to the Centers for Disease Control and Prevention (CDC). The most common HAI is methicillin-resistant Staphylococcus aureus (MRSA). With some MRSA-related projects already underway, Congress directed AHRQ to work with its Federal partners at the CDC and the Centers for Medicare & Medicaid Services to develop an action plan to identify and help reduce the spread of MRSA and related HAIs. The action plan is designed to:
To provide technical assistance and share knowledge and findings , the Agency established a National Resource Center for Health IT. All of the lessons learned from these projects are helping health care providers move closer to a fully operational health IT system in support of improved quality, safety, and continuity of care.
Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering . In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.
In this section, we described conceptual frameworks based on models and theories of human error and organizational accidents (section 2.1), focus on patient care process and system interactions (section 2.2), and models that link healthcare professionals’ performance to patient safety (section 2.3). In the last part of this section, we describe the SEIPS [Systems Engineering Initiative for Patient Safety] model of work system and patient safety that integrates many elements of these other models ( Carayon, et al., 2006 ).
FMEA (Failure Modes and Effects Analysis) is one method that can be used to analyze, redesign and improve healthcare processes to meet the Joint Commission’s National Patient Safety Goals. The National Patient Safety Center of the VA has adapted the industrial FMEA method to healthcare ( DeRosier, Stalhandske, Bagian, & Nudell, 2002 ). FMEA or other proactive risk assessment techniques have been applied to a range of healthcare processes, such as blood transfusion ( Burgmeier, 2002 ), organ transplant (Richard I. Cook, et al., 2007 ), medication administration with implementation of smart infusion pump technology ( Wetterneck, et al., 2006 ), and use of computerized provider order entry ( Bonnabry, et al., 2008 ).
In healthcare, technologies are often seen as an important solution to improve quality of care and reduce or eliminate medical errors (David W. Bates & Gawande, 2003; Kohn, et al., 1999 ). These technologies include organizational and work technologies aimed at improving the efficiency and effectiveness of information and communication processes (e.g., computerized order entry provider and electronic medical record) and patient care technologies that are directly involved in the care processes (e.g., bar coding medication administration). For instance, the 1999 IOM report recommended adoption of new technology, like bar code administration technology, to reduce medication errors ( Kohn, et al., 1999 ). However, implementation of new technologies in health care has not been without troubles or work-arounds (see, for example, the studies by Patterson et al. (2002) and Koppel et al. (2008) on potential negative effects of bar coding medication administration technology). Technologies change the way work is performed ( Smith & Carayon, 1995) and because healthcare work and processes are complex, negative consequences of new technologies are possible ( Battles & Keyes, 2002; R.I. Cook, 2002 ).
Patient safety is about the patient, but requires that healthcare professionals have the right tools and environment to perform their tasks and coordinate their effort. Therefore, it is important to examine patient safety models that focus on the performance of healthcare professionals.
It is important to emphasize that achieving patient safety is a constant process, similar to continuous quality improvement (Shortell et al., 1992). Safety cannot be ‘stored’; safety is an emergent system property that is created dynamically through various interactions between people and the system during the patient journey (see Figures 2 and#N# and3).#N#3 ). Some anticipatory system design can be performed using human factors knowledge (Carayon, Alvarado, & Hundt, 2003, 2006 ). Much is already known about various types of person/system interactions (e.g., usability of technology, appropriate task workload, teamwork) that can produce positive individual and organizational outcomes. However, health care is a dynamic complex system where people and system elements continuously change, therefore requiring constant vigilance and monitoring of the various system interactions and transitions.
System redesign for patient safety should not be achieved at the expense of efficiency. On the contrary, it is important to recognize the possible synergies that can be obtained by patient safety and efficiency improvement efforts.