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Patient Safety: What Is Working and Why?

  • Thomas BartmanEmail author
  • C. Briana Bertoni
  • Jenna Merandi
  • Michael Brady
  • Ryan S. Bode
Patient Safety (M Scanlon, Section Editor)
  • 3 Downloads
Part of the following topical collections:
  1. Topical Collection on Patient Safety

Abstract

Purpose of review

Our goal is to review a number of methodologies which have been used to improve safety in healthcare since the release of the Institute of Medicine report in 1998 which documented that error was a significant cause of mortality in the USA.

Recent findings

Multifaceted approaches have each led to reduction in error. Methods for error reduction included in this review are “Just Culture,” increased transparency and accountability, error reporting and investigation, second-victim programs, training in quality and safety methods, standardization and bundles, electronic health records, computerized order entry, barcode scanning, clinical decision support, predictive analytics, and situational awareness. Newer fields with the potential to improve patient safety include human factors engineering, indication-based prescribing, and Safety II.

Summary

While each intervention has led to incremental improvement, continued expansion of these programs is necessary to eliminate medical error.

Keywords

Patient safety Culture Event reporting Electronic health record Quality improvement Standardization 

Abbreviations

IOM

Institute of Medicine

ADE

Adverse drug event

QI

Quality improvement

HAI

Healthcare acquired infection

CLABSI

Central line-associated bloodstream infection

SSI

Surgical site infection

CAUTI

Catheter-associated urinary tract infection

VAP

Ventilator-associated pneumonia

CDC

Centers for Disease Control

EHR

Electronic health record

HIT

Health information technology

CPOE

Computerized physician order entry

HITECH

Health Information Technology for Economic and Clinical Health

HIPAA

Health Insurance Portability and Accountability Act

CDS

Clinical decision support

ICU

Intensive care unit

RRT

Rapid response team

PEWS

Pediatric Early Warning Score

HFE

Human factors engineering

SEIPS

Systems Engineering Initiative for Patient Safety

ISMP

Institute for Safe Medication Practices

WAD

Work as done

WAI

Work as imagined

Notes

Compliance with Ethical Standards

Conflict of Interest

Thomas Bartman, declares that he has no conflict of interest. C. Briana Bertoni declares that she has no conflict of interest. Jenna Merandi declares that she has no conflict of interest. Michael Brady declares that he has no conflict of interest. Ryan S. Bode declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Thomas Bartman
    • 1
    • 2
    Email author
  • C. Briana Bertoni
    • 3
  • Jenna Merandi
    • 4
  • Michael Brady
    • 2
    • 5
  • Ryan S. Bode
    • 2
    • 6
  1. 1.Quality Improvement ServicesNationwide Children’s HospitalColumbusUSA
  2. 2.Department of PediatricsThe Ohio State University College of MedicineColumbusUSA
  3. 3.Clinical Fellowship in Quality and Safety LeadershipNationwide Children’s HospitalColumbusUSA
  4. 4.Nationwide Children’s HospitalColumbusUSA
  5. 5.Patient SafetyNationwide Children’s HospitalColumbusUSA
  6. 6.Hospital MedicineNationwide Children’s HospitalColumbusUSA

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