TY - BOOK AU - Institute of Medicine A2 - Philip Aspden A2 - Julie Wolcott A2 - J. Lyle Bootman A2 - Linda R. Cronenwett TI - Preventing Medication Errors SN - DO - 10.17226/11623 PY - 2007 UR - https://nap.nationalacademies.org/catalog/11623/preventing-medication-errors PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation's quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series—To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)—this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors. ER - TY - BOOK AU - Institute of Medicine A2 - Ann Page TI - Keeping Patients Safe: Transforming the Work Environment of Nurses SN - DO - 10.17226/10851 PY - 2004 UR - https://nap.nationalacademies.org/catalog/10851/keeping-patients-safe-transforming-the-work-environment-of-nurses PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine KW - Education AB - Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform – monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis – provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care – and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety. ER - TY - BOOK AU - Institute of Medicine A2 - Karen Adams A2 - Janet M. Corrigan TI - Priority Areas for National Action: Transforming Health Care Quality SN - DO - 10.17226/10593 PY - 2003 UR - https://nap.nationalacademies.org/catalog/10593/priority-areas-for-national-action-transforming-health-care-quality PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - A new release in the Quality Chasm Series, Priority Areas for National Action recommends a set of 20 priority areas that the U.S. Department of Health and Human Services and other groups in the public and private sectors should focus on to improve the quality of health care delivered to all Americans. The priority areas selected represent the entire spectrum of health care from preventive care to end of life care. They also touch on all age groups, health care settings and health care providers. Collective action in these areas could help transform the entire health care system. In addition, the report identifies criteria and delineates a process that DHHS may adopt to determine future priority areas. ER - TY - BOOK AU - Institute of Medicine TI - Quality Through Collaboration: The Future of Rural Health SN - DO - 10.17226/11140 PY - 2005 UR - https://nap.nationalacademies.org/catalog/11140/quality-through-collaboration-the-future-of-rural-health PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Building on the innovative Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Quality Through Collaboration: The Future of Rural Health offers a strategy to address the quality challenges in rural communities. Rural America is a vital, diverse component of the American community, representing nearly 20% of the population of the United States. Rural communities are heterogeneous and differ in population density, remoteness from urban areas, and the cultural norms of the regions of which they are a part. As a result, rural communities range in their demographics and environmental, economic, and social characteristics. These differences influence the magnitude and types of health problems these communities face. Quality Through Collaboration: The Future of Rural Health assesses the quality of health care in rural areas and provides a framework for core set of services and essential infrastructure to deliver those services to rural communities. The book recommends: Adopting an integrated approach to addressing both personal and population health needs Establishing a stronger health care quality improvement support structure to assist rural health systems and professionals Enhancing the human resource capacity of health care professionals in rural communities and expanding the preparedness of rural residents to actively engage in improving their health and health care Assuring that rural health care systems are financially stable Investing in an information and communications technology infrastructure It is critical that existing and new resources be deployed strategically, recognizing the need to improve both the quality of individual-level care and the health of rural communities and populations. ER - TY - BOOK AU - Institute of Medicine TI - Crossing the Quality Chasm: A New Health System for the 21st Century SN - DO - 10.17226/10027 PY - 2001 UR - https://nap.nationalacademies.org/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change. ER - TY - BOOK AU - Institute of Medicine AU - National Academies of Sciences, Engineering, and Medicine A2 - Erin P. Balogh A2 - Bryan T. Miller A2 - John R. Ball TI - Improving Diagnosis in Health Care SN - DO - 10.17226/21794 PY - 2015 UR - https://nap.nationalacademies.org/catalog/21794/improving-diagnosis-in-health-care PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errors—has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety. ER - TY - BOOK AU - Institute of Medicine A2 - Linda T. Kohn A2 - Janet M. Corrigan A2 - Molla S. Donaldson TI - To Err Is Human: Building a Safer Health System SN - DO - 10.17226/9728 PY - 2000 UR - https://nap.nationalacademies.org/catalog/9728/to-err-is-human-building-a-safer-health-system PB - The National Academies Press CY - Washington, DC LA - English KW - Health and Medicine AB - Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequence—but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda—with state and local implications—for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors—which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health care—it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates—as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine ER -