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Maternal Cash Transfers Led To Increases In Facility Deliveries And Improved Quality Of Delivery Care In Nigeria.

Published in Health affairs (Project Hope)

Ninety-nine percent of global maternal deaths occur in low- and middle-income countries. The high mortality rates are often attributed to a large portion of births occurring outside of formal health care facilities. This has prompted the creation of programs to promote the use of formal delivery care. However, poor-quality care in health facilities...

Challenges And Opportunities For Improving Patient Safety Through Human Factors And Systems Engineering.

Published in Health affairs (Project Hope)

Despite progress on patient safety since the publication of the Institute of Medicine's 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex in...

Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In Two Data Sets.

Published in Health affairs (Project Hope)

Chart-based surveillance reviews indicate that the incidence of hospital-acquired pressure ulcers (HAPUs) declined 23 percent during 2010-14, equating to an estimated savings of $1 billion during that period. Yet it remains unclear whether the administrative data used to implement three Medicare value-based purchasing programs that target HAPUs ind...

Scaling Safety: The South Carolina Surgical Safety Checklist Experience.

Published in Health affairs (Project Hope)

Proven patient safety solutions such as the World Health Organization's Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that reported completing implementation of the checklist in their operati...

Does Nursing Home Compare Reflect Patient Safety In Nursing Homes?

Published in Health affairs (Project Hope)

The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy ...

Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy.

Published in Health affairs (Project Hope)

Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence, understaffing, sexual assault, inappropr...

Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety.

Published in Health affairs (Project Hope)

The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. Highly effective interventions have since been developed and adopted for hospit...

Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers.

Published in Health affairs (Project Hope)

Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-...

Accurate Measurement In Californias Safety-Net Health Systems Has Gaps And Barriers.

Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-...