| Tittel: | Making healthcare safer III : A critical analysis of existing and emerging patient safety practices | | Signatur: | Elektronisk dokument | | Materialtype: | Elektronisk dokument | | Utgitt: | Rockville, MD : Agency for Healthcare Research and Quality, 2020 | | Omfang: | flere pag. | | Serie: | AHRQ Publication ; No. 20-0029-EF  | | Emneord: | Evaluering / Kunnskapsbasert praksis / Kunnskapsoppsummering / Kvalitetssikring / Medisinsk metodevurdering / Pasientsikkerhet / Uønskede hendelser | | Note: | Chapters:
Diagnostic Errors
Failure To Rescue
Sepsis Recognition
Clostridioides difficile Infection
Infections Due to Other Multidrug-Resistant Organisms
Carbapenem-Resistant Enterobacteriaceae
Harms Due to Anticoagulants
Harms Due to Diabetic Agents
Reducing Adverse Drug Events in Older Adults
Harms Due to Opioids
Patient Identification Errors in the Operating Room
Infusion Pumps
Alarm Fatigue
Delirium
Care Transitions
Venous Thromboembolism
Cross-Cutting Patient Safety Topics/Practices | | Innhold: | The amount of published research in patient safety has exponentially grown since the last AHRQ “Making Health Care Safer” report was published in 2013, albeit with publications varying in quality. PSPs that are more well-established are now being investigated in light of emerging harms, such as the applicability of infection-prevention-related PSPs to address the threat from multidrug-resistant organisms. Similarly, emerging PSPs are being investigated for use to address well-established harms, such as the use of clinical decision support to reduce diagnostic errors. It is clear that a wide range of factors impact the effectiveness of PSPs with respect to their ability to prevent harm.
The five major threats to safety that were addressed include medication management issues, healthcare-associated infections, nursing sensitive events, procedural events, and diagnostic errors; and the report covers 47 PSPs in 17 specific harm areas. The PSPs were chosen for inclusion in the report based on the high-impact harms they address and interest in the status of their appropriateness for use. While the team was going through the process of selecting PSPs to address specific harm areas, it became evident that several cross-cutting contextual factors should also be reviewed. These cross-cutting practices are improving safety culture; teamwork and team training; clinical decision support; person and family engagement; cultural and linguistic competency; staff education and training; and data monitoring, audit, and feedback.
| | Eier: | HELSTILS |
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