Abstract
Knowledge and skills in patient safety and quality improvement principles and processes are vital for geriatricians to ensure high-quality and safe care for older adults. It is critical that all members of the healthcare team understand the overarching principles and specific processes and metrics to identify medical errors and quality problems to prevent harm to patients. Additionally, familiarity with key agencies such as the Agency for Healthcare Research and Quality (AHRQ) (https://www.ahrq.gov/) and the Institute for Healthcare Improvement (IHI) (http://www.ihi.org/) that are leaders in quality and safety will assist the team in their ability to access evidence-based resources and toolkits and contribute to optimal care in their practices. Geriatricians and other geriatric-trained health professionals provide care to some of the most vulnerable patients; attention to patient safety and participation in quality improvement are essential to providing excellent care.
References
OECD Health Statistics. WHO global health expenditure database. 2021. https://www.oecd-ilibrary.org/sites/ae3016b9-en/1/3/7/2/index.html?itemId=/content/publication/ae3016b9-en&_csp_=ca413da5d44587bc56446341952c275e&itemIGO=oecd&itemContentType=book
Mahon M, Fox B. US health system ranks last among eleven countries on measures of access, equity, quality, efficiency and healthy lives. New York: The Commonwealth Fund; New York, 2014.
Teisberg E, Wallace S, O’Hara S. Defining and implementing value-based health care: a strategic framework. Acad Med. 2020;95(5):682.
Agency for Healthcare Research and Quality: PSNet. Patient safety 101: the fundamentals. n.d.. https://psnet.ahrq.gov/patient-safety-101, paragraph 1.
Agency for Healthcare Research and Quality: PSNet. Glossary: error. n.d.. https://psnet.ahrq.gov/taxonomy/term/3475#:~:text=Error%20%7C%20PSNet&text=An%20act%20of%20commission%20 (doing,be%20an%20act%20of%20commission
Agency for Healthcare Research and Quality: PSNet. Practice facilitation handbook module 4. Approaches to quality improvement. n.d.. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.html
Institute of Medicine. To err is human: building a safer health system. Washington, DC: The National Academies Press; 2000. https://doi.org/10.17226/9728.
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The National Academies Press; 2001. https://doi.org/10.17226/10027.
Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759–69.
Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–6.
Anderson P. Physicians experience highest suicide rate of any profession. In: Medscape, Conf News 2018. p. 1–2.
Sanchez S, Mahmoudi R, Moronne I, Camonin D, Novella JL. Burnout in the field of geriatric medicine: review of the literature. Eur Geriatr Med. 2015;6(2):175–83.
Perni S, Pollack LR, Gonzalez WC, et al. Moral distress and burnout in caring for older adults during medical school training. BMC Med Educ. 2020;20:84. https://doi.org/10.1186/s12909-020-1980-5.
Goldberg DG, Soylu TG, Grady VM, Kitsantas P, Grady JD, Nichols LM. Indicators of workplace burnout among physicians, advanced practice clinicians, and staff in small to medium-sized primary care practices. J Am Board Fam Med. 2020;33(3):378–85.
Maslach C. Finding solutions to the problem of burnout. Consult Psychol J Pract Res. 2017;69(2):143.
National Academies of Sciences, Engineering, and Medicine. Communities in action: pathways to health equity. https://www.nap.edu/download/24624
Institute of Medicine. Future directions for the National Healthcare Quality and Disparities reports. Washington, DC: The National Academies Press. Based on the work of a joint ASHP-ACPE Task Force. AACP Annual Meeting; 2010.
Association of American Medical Colleges. Quality Improvement and Patient Safety Competencies (QIPS). https://store.aamc.org/downloadable/download/sample/sample_id/302/
Barnsteiner J, Disch J, Johnson J, McGuinn K, Chappell K, Swartwout E. Diffusing QSEN competencies across schools of nursing: the AACN/RWJF faculty development institutes. J Prof Nurs. 2013;29(2):68–74.
Henriksen K, Battles JB, Keyes MA, Grady ML. Advances in patient safety: new directions and alternative approaches. AHRQ Publication; 2008 (08-0034).
Hospital National Patient Safety Goals. 2022. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/simple_2022-hap-npsg-goals-101921.pdf
Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260(12):1743–8.
Agency for Healthcare Research and Quality: PSNet. Glossary: medical error. n.d.. https://psnet.ahrq.gov/issue/medical-error
Agency for Healthcare Research and Quality: PSNet. Adverse events, near misses, and errors. 2019. https://psnet.ahrq.gov/issue/medical-error
Bishop TJ, Ryan AM, Casalino LP. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA. 2016;305(23):2417–31.
Agency for Healthcare Research and Quality: PSNet. Glossary: underuse, overuse, misuse. n.d.. https://psnet.ahrq.gov/glossary-0#glossary-heading-term-73844
Agency for Healthcare Research and Quality: PSNet. Never events. 2019. https://psnet.ahrq.gov/primer/never-events
Parker J. Root cause analysis in health care: tools and techniques. The Joint Commission. https://www.jcrinc.com/-/media/deprecated-unorganized/imported-assets/jcr/default-folders/items/ebrca15samplepdf.pdf?db=web&hash=D9A527F917C81876009A950394FE8D69
Patient Safety 104: Root Cause and Systems Analysis. IHI Open School. http://www.ihi.org/education/ihiopenschool/Courses/Documents/SummaryDocuments/PS%20104%20SummaryFINAL.pdf
Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf. 2014;23:196–205.
Flin R, Winter J, Sarac C, Raduma M. Human factors in patient safety: review of topics and tools. World Health. 2009;2:11–2. https://www.who.int/patientsafety/research/methods_measures/human_factors/human_factors_review.pdf
Wiegmann DA, Wood LJ, Cohen TN, Shappell SA. Understanding the “Swiss cheese model” and its application to patient safety. J Patient Saf. 2022;18(2):119–23.
Henriksen K, Battles JB, Keyes MA, et al., editors. Rockville: Agency for Healthcare Research and Quality; Advances in patient safety: new directions and alternative approaches. AHRQ Publication, (08–0034) 2008.
Boysen PG. Just culture: a foundation for balanced accountability and patient safety. Ochsner J. 2013;13(3):400–6.
Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manag Rev. 2009;34(4):312–22.
Agency for Healthcare Research and Quality. AHRQ CUSP model. https://www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
Paradiso L, Sweeney N. Just culture: it’s more than policy. Nurs Manag. 2019;50(6):38.
AHRQ CUSP Toolkit. Understand just culture. https://www.ahrq.gov/hai/cusp/videos/07a-just-culture/index.html
Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22(Suppl 2):ii21–7.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.
Díaz Hernández SH, Cruz-Gonzalez I. Incidence and preventability of medication errors and ADEs in ambulatory care older patients. Consult Pharm. 2018;33(8):454–66.
Lee JL, Dy SM, Gurses AP, Kim JM, Suarez-Cuervo C, Berger ZD, Brown R, Xiao Y. Towards a more patient-centered approach to medication safety. J Patient Exp. 2018;5(2):83–7.
Fisher KA, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experience. BMJ Qual Saf. 2018;28(3):190–7.
Silver SA, Harel Z, McQuillan R, Weizman AV, Thomas A, Chertow GM,…Chan CT. How to begin a quality improvement project. Clin J Am Soc Nephrol CJASN. 2016;11(5):893.
Institute for Healthcare Improvement. How to improve. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
Bahensky JA, Roe J, Bolton R. Lean sigma–will it work for healthcare. J Healthc Inf Manag. 2005;19(1):39–44.
Montgomery DC, Woodall WH. An overview of six sigma. Int Stat Rev/Rev Int Stat. 2008;1:329–46.
De Koning H, Verver JP, van den Heuvel J, Bisgaard S, Does RJ. Lean six sigma in healthcare. J Healthc Qual. 2006;28(2):4–11.
Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? BMJ Qual Saf. 2007;16(1):2–3.
Lau CY. Quality improvement tools and processes. Neurol Clin. 2015;26(2):177–87.
Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: what does the literature tell us? Jt Comm J Qual Patient Saf. 2008;34(7):391–8.
McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. J Br Surg. 2011;98(4):469–79.
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Bakerjian, D. (2024). Improving Quality and Safety in the Care of Older Adults. In: Wasserman, M.R., Bakerjian, D., Linnebur, S., Brangman, S., Cesari, M., Rosen, S. (eds) Geriatric Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-74720-6_100
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