52,295 research outputs found
Developing and Implementing Self-Direction Programs and Policies: A Handbook
Provides a guide to designing, implementing, and evaluating service delivery models that allow public program participants to manage their own care services and supports. Outlines elements of employer and budget authorities, enrollment, and counseling
Patient safety in Europe: medication errors and hospital-acquired infections
The Report was commissioned by the European Federation of Nurses Associations (EFN) in November 2007 in order to support its policy statements on Patient Safety (June 2004). In that statement the EFN declares its belief that European Union health services should operate within a culture of safety that is based on working towards an open culture and the immediate reporting of mistakes; exchanging best practice and research; and lobbying for the systematic collection of information and dissemination of research findings. This Report adressess specifically the culture of highly reliable organisations using the work of James Reason (2000). Medication errors and hospital-acquired infections are examined in line with the Reprt´s parameters and a range of European studies are used as evidence. An extensive reference list is provided that allows EFN to explore work in greater detail as required
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement
Examines four healthcare systems' expansion of patient safety interventions over five years through the development of practical training methods, effective tools for minimizing errors, an emphasis on goal setting and accountability, and other approaches
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officer’s report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agency’s progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHS’s patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Department’s strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Department’s clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authority’s
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
Assessment and Comparison of Behavior Risk Factor Surveillance Systems for the U.S., Canada, and Italy.
Behavior risk factors include health risk factors that increase a person\u27s chances of developing a disease, such as having a high blood pressure, high blood cholesterol, tobacco smoke, physical inactivity, obesity or overweight, diabetes, poor nutrition, lack of sex education and car safety. They can be classified as: Background risk factors, such as age, sex, level of education and genetic compositions; Behavioral risk factors, such as smoking, unhealthy diet and physical inactivity; and Intermediate risk factors, such a serum cholesterol levels, diabetes, hypertension and obesity/overweight. This study describes a comparison and assessment of Behavior Risk Factor Surveillance Systems for the U.S., Canada, and Italy. The aim of this project is to assess and analyze the behavior surveillance systems of U.S., Canada and Italy, compare their strengths and weaknesses and provide recommendations that can be used as a guide for the design of new BRFS systems or the assessment of existing systems. The purpose of the assessment is to identify ways of improving the respective systems, and also to compare public health BRFS systems in the three different countries. The attributes used in the evaluation of the systems include simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability. The criteria and standards are based on the CDC Guidelines for Evaluating Surveillance Systems published on 1988 and updated on 2001
Improving Quality and Achieving Equity: A Guide for Hospital Leaders
Outlines the need to address racial/ethnic disparities in health care, highlights model practices, and makes step-by-step recommendations on creating a committee, collecting data, setting quality measures, evaluating, and implementing new strategies
Parents Behind Bars: What Happens to Their Children?
Children do not often figure in discussions of incarceration, but new research finds more than five million U.S. children have had at least one parent in prison at one time or another -- about three times higher than earlier estimates that included only children with a parent currently incarcerated. This report uses the National Survey of Children's Health to examine both the prevalence of parental incarceration and child outcomes associated with it.Previous research has found connections between parental incarceration and childhood health problems, behavior problems, and grade retention. It has also been linked to poor mental and physical health in adulthood
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