Paving the Way for Progress: The Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative

Battles, James B; Reback, Kathryn; Azam, Irim

doi:10.1111/1475-6773.12632

Cited by 6 publications

(5 citation statements)

References 20 publications

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“…In this medical group, the pharmacists made frequent modifications to the patients' medication therapy related to medication appropriateness, dosing, adherence, and other clinical considerations. Given that other studies have found that patients have 4-7 medication discrepancies upon discharge from the hospital, 22,23 the incorporation of CMM into routine transitional care can significantly improve patient outcomes. Health systems and medical groups looking to optimize the effectiveness of their own TOC programs may consider expanding the role of their pharmacists to include CMM as part of an integrated, team-based care approach.…”

Section: Discussionmentioning

confidence: 99%

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group’s Transition of Care Services

et al. 2021

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Objectives: Evaluate the impact of pharmacist-provided transition of care (TOC) services on hospital readmissions.Methods: Starting March 2014, TOC services were provided to all hospitalized patients from an at-risk medical group. Data covering all inpatient and outpatient services and prescription drugs were retrieved for all adult patients discharged between January 2010 and December 2018. The overall impact of TOC was estimated using a generalized estimating equation with logistic regression. Longitudinal TOC effects were estimated using generalized estimating equation in an interrupted time series model. Parallel analyses were conducted using data from an affiliated medical group in a neighboring county without access to the TOC intervention.Results: The study included 13,256 hospital discharges for adult patients for the 30-day readmission analysis and 10,740 discharges for the 180 days analysis. The TOC program reduced 30-day readmission risk by 34.9% [odds ratio (OR) = 0.651 (range, 0.590-0.719)] and 180-day readmissions by 33.4% [OR = 0.666 (range, 0.604-0.735)]. The interrupted time series results found the 30-day readmission rate to be stable over the pre-TOC period (OR = 0.00; not significant) then to decreased by 1.5% per month in the post-TOC period [OR = 0.985 (range, 0.980-0.991)]. For 180-day readmissions, risk decreased by 1% per month after TOC implementation [OR = 0.990 (range, 0.984-0.996)]. Referral to the medical group's pre-existing Priority Care clinic also reduced readmission risk. Results from the comparison medical group found 180-day readmission declined by 1% per month after March 2014 [OR = 0.990 (0.891-1.00)].Conclusions: Adding a pharmacist-led TOC program to the medical group's existing outpatient services reduced 30-and 180-day readmissions by "bending the curve" for readmission risk over time.

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Section: Discussionmentioning

confidence: 99%

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group’s Transition of Care Services

et al. 2021

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“…We coded these occurrences as ‘near misses’—defined by the Agency for Healthcare and Research Quality as, ‘errors that occur in the process of providing medical care that are detected and corrected before a patient is harmed’. 14 These messages were flagged and then later reviewed by a physician (MW) and two other reviewers (CED and JLL) to confirm the near misses and assess the severity of the potential magnitude of harm of each near miss. Near misses were coded according to type (errors of omission, commission, delay in care and general communication errors) and potential magnitude of harm (low, medium and high).…”

Section: Methodsmentioning

confidence: 99%

Texting is caring: a content analysis of clinical text messages by hospitalists

Donnelly,

Flores,

Weiner

et al. 2023

BMJ Open Qual

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BackgroundClinical texting systems (CTS) are widely used in hospitals for team communication about patients. With more institutions adopting such systems, there is a need to understand how texting is being used in clinical practice.MethodsWe conducted content analysis of 809 randomly selected message threads sent to and from hospitalists in a 9-month window. The process, purpose and content of messages were analysed. We also examined messages for personal content (to identify whether CTS was being used for professional matters) and discussion of near miss errors. The risk levels of these near misses were also assessed.ResultsMost messages focused on clinical management of patient needs (62%; n=498) and functioned to provide a notification or update regarding clinical care (64%; n=518) or make a request of the recipient (63%; n=510). Personal content was infrequent in message threads (10%; n=80). Five per cent (n=38) of message threads included discussion of a near miss, and most near misses posed low clinical risk overall (66%; n=25).ConclusionMost CTS communication centred around direct clinical management. Fewer messages were focused on non-clinical areas such as administrative tasks or personal communication. Further examination of care delivery, error communication and the consequences of the care discussed in messages would help clinical leaders understand the impact of clinical texting on teamwork and quality of care.

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“…Module (2) presented the frame of the MED process, which outlined the necessary steps (when, where, and how disclosure should take place; what should be disclosed and documented; and who are the disclosing teams?). While module (3) presented the MED process through a quick guide diagram that adapted from the communication and optimal resolution process (CANDOR), it included improvisational methods of communication, empathic communication skills, and how to apologize (Battles, et al, 2017). Instructional guidelines sessions were planned to include numbers of sessions, the estimated session time, the session's specific objectives, and the required materials.…”

Section: Pilot Studymentioning

confidence: 99%

Effect of Instructional Guidelines on Nurses' Perceived Barriers Regarding Medical Errors Disclosure

Mohamed,

Elsaid,

Fadel

et al. 2023

Assiut Scientific Nursing Journal

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Background: Despite global efforts, medical errors continue to pose a serious challenge to patient safety. Between the need for medical error disclosure as a key tool for error prevention and the fear of disclosures' negative threats, nurses are confronted with challenges and barriers to disclosing and reporting medical errors. Aim: The current study aimed to evaluate the effect of instructional guidelines on nurses' perceived barriers regarding medical error disclosure. Design: A quasi-experimental design with one group (pretest and posttest) was used. Setting: The study was carried out at inpatient departments and outpatient clinics affiliated to Mansoura University Hospital, Egypt. Subjects: A purposive sample of 100 nurses with different educational levels were eligible to be enrolled in the study. Tools: The researchers using two tools: Nurses' demographic characteristics, and professional data questionnaire, and the barriers to error disclosure assessment tool. Results: The results showed that all the studied nurses (100%) were exposed to medical errors and had barriers to disclosing them. Nurses' knowledge and confidence abilities to disclose medical errors were the most significant perceived barriers, with total mean scores of 4.37±0.43. After implementing instructional guidelines, nurses' perceived barriers regarding medical error disclosure significantly differed (t = 58.918 & p = 0.000), in which the total mean score of the perceived barriers improved to 2.89±0.33 post-implementing the guidelines compared to 4.24±0.36 pre-implementing the guidelines. Conclusion:The current study concluded that empowering the studied nurses by implementing the instructional guidelines had a positive effect on their perceived barriers regarding medical error disclosure. Recommendations: Raising nurses awareness regarding medical error disclosure by adding disclosure guidelines to the curricula of educational nursing institutions, in addition to incorporating them into ongoing in-service training programs at different health care settings.

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Paving the Way for Progress: The Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative

Cited by 6 publications

References 20 publications

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group’s Transition of Care Services

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group’s Transition of Care Services

Texting is caring: a content analysis of clinical text messages by hospitalists

Effect of Instructional Guidelines on Nurses' Perceived Barriers Regarding Medical Errors Disclosure

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