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The 20th anniversary of “To Err is Human”: Improving patient safety

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AHRQ: One Decade after To Err Is Human

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Add a review and share your thoughts with other readers. Creating a culture of safety. The tools can provide a baseline for organizations to track changes over time and evaluate the impact of patient safety interventions.


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Today, more than hospitals share their culture survey data, allowing hospitals to compare their efforts. Encouraging teamwork. Culled in part from effective practices to boost team coordination among flight crews, TeamSTEPPS has been distributed to 14, healthcare organizations.

To Err is Human

Today, AHRQ has supported a cadre of master team trainers who help organizations implement team-based approaches to care. Reducing healthcare-associated infections. The intervention includes hand-washing and other practices that lead to substantial and sustained reductions in infections. Preventing medication errors. Warfarin is the second most common drug after insulin implicated in emergency room visits for adverse drug events AHRQ, Reducing hospital readmissions.

An AHRQ toolkit helps hospitals re-engineer their discharge processes to prevent unnecessary patient readmissions. Advances in event reporting.

References

Event reporting and standardized data collection will soon yield crucial data, thanks to federal efforts to create Patient Safety Organizations PSOs , which were authorized under the Patient Safety and Quality Improvement Act. The PSOs, listed by AHRQ, this year began to receive and analyze patient safety data, while working with providers to improve care without fear of legal discovery.

While we can detect and document striking increases in interest and awareness of patient safety problems, documenting improved performance is far more challenging, as it can be difficult to tell increased rates of reporting from increases or decreases in the actual incidence of the underlying events. This effort should enhance our ability to know whether our aspirations for providing safer care, and those of providers, match reality over time.

Supporting patient safety training. To better prepare physicians and surgeons for high-risk events, AHRQ supports several projects that assess the use of simulation technology in improving teamwork, communication, diagnostic and technical skills, safety culture, and several other hallmarks of safe care provision. Understanding resident fatigue.


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AHRQ-supported research into medical resident fatigue and its connection to medical errors prompted limits in on the hours per week that medical residents could work at U. Our accomplishments include increased awareness of the problem, the creation of an AHRQ-led knowledge base, development of useful tools, increased attention to systems approaches to reduce medical errors and healthcare-associated infections, creation of PSOs, the training of workers in safety concepts, as well as the development of event reporting systems and establishment of national data collection standards.

Going forward, protecting patients from preventable medical harm requires a continuation of the work currently underway, continued production and dissemination of evidence-based tools and solutions that make it easier for frontline healthcare workers to provide care in a coordinated and safe manner, and creation of incentives to help ensure that the right care is delivered at the right time — every time. The time has come to update the patient safety roadmap for the next decade. A new national summit or conversation could yield a more sharply defined plan that stakes out both practical steps and goals and updates national patient safety policy.

Practical steps could involve the creation of teams within healthcare organizations that routinely examine errors and quickly address how to resolve them.


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Other steps could involve the widespread use of patient and family advisory councils, so patients can become better-educated consumers and bring their valuable insights to key safety improvement measures. Patients are critical partners as we strive to deliver timely, safe, effective, patient-centered care. As we look to the decade ahead in patient safety improvement, AHRQ will continue its mission of discovering, designing, and disseminating tools and solutions that make safer patient care not just the right thing to do but also the easy thing to do.

Our goal is to ensure that evidence-based patient safety practices will become routine in every healthcare setting. I am energized by the progress made to date and by the continuing commitment my fellow clinicians and health organizations have already made toward realizing this goal. I hope you are, too. References Institute of Medicine. To err is human: Building a safer health system.

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Accessed July Agency for Healthcare Research and Quality. National healthcare quality report Patient safety culture surveys. Pronovost, P. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 26 , Blood thinners: Your guide to using them safely. Forster, A.

The incidence and severity of adverse events affecting patients after discharge from the hospital.