%0 Book %A Institute of Medicine %E Aspden, Philip %E Wolcott, Julie %E Bootman, J. Lyle %E Cronenwett, Linda R. %T Preventing Medication Errors %@ 978-0-309-10147-9 %D 2007 %U https://nap.nationalacademies.org/catalog/11623/preventing-medication-errors %> https://nap.nationalacademies.org/catalog/11623/preventing-medication-errors %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 480 %X 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. %0 Book %A National Academies of Sciences, Engineering, and Medicine %E Alper, Joe %T Communicating Clearly About Medicines: Proceedings of a Workshop %@ 978-0-309-46185-6 %D 2017 %U https://nap.nationalacademies.org/catalog/24814/communicating-clearly-about-medicines-proceedings-of-a-workshop %> https://nap.nationalacademies.org/catalog/24814/communicating-clearly-about-medicines-proceedings-of-a-workshop %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 124 %X Research conducted over the past two decades has shown that poor patient understanding of medication instructions is an important contributor to the more than 1 million medication errors and adverse drug events that lead to office and emergency room visits, hospitalizations, and even death. Patients who have limited literacy skills, who have multiple comorbidities, and who are elderly face the greatest risk, and limited literacy skills are significantly associated with inadequate understanding and use of prescription instructions and precautions. The Agency for Healthcare Research and Quality notes that only 12 percent of U.S. adults have proficient health literacy that allows them to interpret a prescription label correctly. Given the importance of health literacy to the proper use of medications, and the apparent lack of progress in improving medication adherence, the Roundtable on Health Literacy formed an ad hoc committee to plan and conduct a 1-day public workshop that featured invited presentations and discussion of the role and challenges regarding clarity of communication on medication. Participants focused on using health literacy principles to address clarity of materials, decision aids, and other supportive tools and technologies regarding risks, benefits, alternatives, and health plan coverage. This publication summarizes the presentations and discussions from the workshop. %0 Book %A National Academies of Sciences, Engineering, and Medicine %E Alper, Joe %T Building the Case for Health Literacy: Proceedings of a Workshop %@ 978-0-309-47429-0 %D 2018 %U https://nap.nationalacademies.org/catalog/25068/building-the-case-for-health-literacy-proceedings-of-a-workshop %> https://nap.nationalacademies.org/catalog/25068/building-the-case-for-health-literacy-proceedings-of-a-workshop %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 170 %X The field of health literacy has evolved from one focused on individuals to one that recognizes that health literacy is multidimensional. While communicating in a health literate manner is important for everyone, it is particularly important when communicating with those with limited health literacy who also experience more serious medication errors, higher rates of hospitalization and use of the emergency room, poor health outcomes, and increased mortality. Over the past decade, research has shown that health literacy interventions can significantly impact various areas including health care costs, outcomes, and health disparities. To understand the extent to which health literacy has been shown to be effective at contributing to the Quadruple Aim of improving the health of communities, providing better care, providing affordable care, and improving the experience of the health care team, the National Academies of Sciences, Engineering, and Medicine convened a public workshop on building the case for health literacy. This publication summarizes the presentations and discussions from the workshop, and highlights important lessons about the role of health literacy in meeting the Quadruple Aim, case studies of organizations that have adopted health literacy, and discussions among the different stakeholders involved in making the case for health literacy. %0 Book %A Institute of Medicine %E Hernandez, Lyla M. %T How Can Health Care Organizations Become More Health Literate?: Workshop Summary %@ 978-0-309-25681-0 %D 2012 %U https://nap.nationalacademies.org/catalog/13402/how-can-health-care-organizations-become-more-health-literate-workshop %> https://nap.nationalacademies.org/catalog/13402/how-can-health-care-organizations-become-more-health-literate-workshop %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 122 %X Approximately 80 million adults in the United States have low health literacy - an individual's ability to obtain, process, and understand basic health information. Low health literacy creates difficulties in communicating with clinicians, poses barriers in managing chronic illness, lessens the likelihood of receiving preventive care, heightens the possibility of experiencing serious medication errors, increased risk of hospitalization, and results in poorer quality of life. It is important for health care organizations to develop strategies that can improve their health literacy, yet organizations often find it difficult to determine exactly what it means to be health literate. How Can Health Care Organizations Become More Health Literate?: Workshop defines a health literate health care organization as "an organization that makes it easier for people to navigate, understand, and use information and services to take care of their health." In November 2011, the IOM Roundtable on Health Literacy held a workshop to discuss the growing recognition that health literacy depends not only on individual skills and abilities but also on the demands and complexities of the health care system. How Can Health Care Organizations Become More Health Literate?: Workshop summarizes the workshop. %0 Book %T %D %U %> %I The National Academies Press %C Washington, DC %G English %P %0 Book %A Institute of Medicine %E Baciu, Alina %E Stratton, Kathleen %E Burke, Sheila P. %T The Future of Drug Safety: Promoting and Protecting the Health of the Public %@ 978-0-309-10304-6 %D 2007 %U https://nap.nationalacademies.org/catalog/11750/the-future-of-drug-safety-promoting-and-protecting-the-health %> https://nap.nationalacademies.org/catalog/11750/the-future-of-drug-safety-promoting-and-protecting-the-health %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 346 %X In the wake of publicity and congressional attention to drug safety issues, the Food and Drug Administration (FDA) requested the Institute of Medicine assess the drug safety system. The committee reported that a lack of clear regulatory authority, chronic underfunding, organizational problems, and a scarcity of post-approval data about drugs&#39 risks and benefits have hampered the FDA&#39s ability to evaluate and address the safety of prescription drugs after they have reached the market. Noting that resources and therefore efforts to monitor medications&#39 risk–benefit profiles taper off after approval, The Future of Drug Safety offers a broad set of recommendations to ensure that consideration of safety extends from before product approval through the entire time the product is marketed and used. %0 Book %A Institute of Medicine %E Kohn, Linda T. %E Corrigan, Janet M. %E Donaldson, Molla S. %T To Err Is Human: Building a Safer Health System %@ 978-0-309-26174-6 %D 2000 %U https://nap.nationalacademies.org/catalog/9728/to-err-is-human-building-a-safer-health-system %> https://nap.nationalacademies.org/catalog/9728/to-err-is-human-building-a-safer-health-system %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 312 %X 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 %0 Book %A National Academies of Sciences, Engineering, and Medicine %E French, Melissa G. %E Alper, Joe %T Communicating Clearly About Medicines: Proceedings of a Workshop—in Brief %D 2017 %U https://nap.nationalacademies.org/catalog/24785/communicating-clearly-about-medicines-proceedings-of-a-workshop-in-brief %> https://nap.nationalacademies.org/catalog/24785/communicating-clearly-about-medicines-proceedings-of-a-workshop-in-brief %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 7 %X On November 17, 2016, the Roundtable on Health Literacy of the National Academies of Sciences, Engineering, and Medicine convened a workshop on communicating clearly about medicines. The workshop focused on the clarity of written information given to patients and consumers as printed or digital materials. Participants explored the design of health-literate written materials and examples that illustrated implementation of research into the development of these materials. This publication summarizes the presentations and discussions from the workshop. %0 Book %A Institute of Medicine %E Hernandez, Lyla M. %T Standardizing Medication Labels: Confusing Patients Less: Workshop Summary %@ 978-0-309-11529-2 %D 2008 %U https://nap.nationalacademies.org/catalog/12077/standardizing-medication-labels-confusing-patients-less-workshop-summary %> https://nap.nationalacademies.org/catalog/12077/standardizing-medication-labels-confusing-patients-less-workshop-summary %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 116 %X Medications are an important component of health care, but each year their misuse results in over a million adverse drug events that lead to office and emergency room visits as well as hospitalizations and, in some cases, death. As a patient's most tangible source of information about what drug has been prescribed and how that drug is to be taken, the label on a container of prescription medication is a crucial line of defense against such medication safety problems, yet almost half of all patients misunderstand label instructions about how to take their medicines. Standardizing Medication Labels: Confusing Patients Less is the summary of a workshop, held in Washington, D.C. on October 12, 2007, that was organized to examine what is known about how medication container labeling affects patient safety and to discuss approaches to addressing identified problems. %0 Book %A Institute of Medicine %T Health IT and Patient Safety: Building Safer Systems for Better Care %@ 978-0-309-22112-2 %D 2012 %U https://nap.nationalacademies.org/catalog/13269/health-it-and-patient-safety-building-safer-systems-for-better %> https://nap.nationalacademies.org/catalog/13269/health-it-and-patient-safety-building-safer-systems-for-better %I The National Academies Press %C Washington, DC %G English %K Computers and Information Technology %K Health and Medicine %P 234 %X IOM's 1999 landmark study To Err is Human estimated that between 44,000 and 98,000 lives are lost every year due to medical errors. This call to action has led to a number of efforts to reduce errors and provide safe and effective health care. Information technology (IT) has been identified as a way to enhance the safety and effectiveness of care. In an effort to catalyze its implementation, the U.S. government has invested billions of dollars toward the development and meaningful use of effective health IT. Designed and properly applied, health IT can be a positive transformative force for delivering safe health care, particularly with computerized prescribing and medication safety. However, if it is designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care. Poorly designed IT can introduce risks that may lead to unsafe conditions, serious injury, or even death. Poor human-computer interactions could result in wrong dosing decisions and wrong diagnoses. Safe implementation of health IT is a complex, dynamic process that requires a shared responsibility between vendors and health care organizations. Health IT and Patient Safety makes recommendations for developing a framework for patient safety and health IT. This book focuses on finding ways to mitigate the risks of health IT-assisted care and identifies areas of concern so that the nation is in a better position to realize the potential benefits of health IT. Health IT and Patient Safety is both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use of health IT. This book will be of interest to the health IT industry, the federal government, healthcare providers and other users of health IT, and patient advocacy groups. %0 Book %A Institute of Medicine %E Adams, Karen %E Corrigan, Janet M. %T Priority Areas for National Action: Transforming Health Care Quality %@ 978-0-309-08543-4 %D 2003 %U https://nap.nationalacademies.org/catalog/10593/priority-areas-for-national-action-transforming-health-care-quality %> https://nap.nationalacademies.org/catalog/10593/priority-areas-for-national-action-transforming-health-care-quality %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 159 %X 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. %0 Book %A Institute of Medicine %E Aspden, Philip %E Corrigan, Janet M. %E Wolcott, Julie %E Erickson, Shari M. %T Patient Safety: Achieving a New Standard for Care %@ 978-0-309-09077-3 %D 2004 %U https://nap.nationalacademies.org/catalog/10863/patient-safety-achieving-a-new-standard-for-care %> https://nap.nationalacademies.org/catalog/10863/patient-safety-achieving-a-new-standard-for-care %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 550 %X Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed — a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data. %0 Book %A Institute of Medicine %A Institute of Medicine %T The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety %@ 978-0-309-21803-0 %D 2011 %U https://nap.nationalacademies.org/catalog/13217/the-richard-and-hinda-rosenthal-lecture-2011-new-frontiers-in %> https://nap.nationalacademies.org/catalog/13217/the-richard-and-hinda-rosenthal-lecture-2011-new-frontiers-in %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 42 %X More than 10 years ago, the IOM released its landmark report on patient safety, To Err is Human: Building a Safer Health System. The 2011 Rosenthal Lecture featured the Honorable Kathleen G. Sebelius, Secretary of the U.S. Department of Health and Human Services, who presented the new steps that HHS is taking to improve patient safety. A panel of leaders in patient safety followed to discuss patient safety progress and opportunities. %0 Book %A Institute of Medicine %E Vancheri, Cori %T The Safe Use Initiative and Health Literacy: Workshop Summary %@ 978-0-309-15931-9 %D 2010 %U https://nap.nationalacademies.org/catalog/12975/the-safe-use-initiative-and-health-literacy-workshop-summary %> https://nap.nationalacademies.org/catalog/12975/the-safe-use-initiative-and-health-literacy-workshop-summary %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 90 %X Every year at least 1.5 million people suffer adverse effects from medication. These problems occur because people misunderstand labels, are unaware of drug interactions, or otherwise use medication improperly. The Food and Drug Administration's Safe Use Initiative seeks to identify preventable medication risks and develop solutions to them. The IOM held a workshop to discuss the FDA's Safe Use Initiative and other efforts to improve drug labeling and safety. %0 Book %A Institute of Medicine %T Informing the Future: Critical Issues in Health: Fourth Edition %D 2007 %U https://nap.nationalacademies.org/catalog/12014/informing-the-future-critical-issues-in-health-fourth-edition %> https://nap.nationalacademies.org/catalog/12014/informing-the-future-critical-issues-in-health-fourth-edition %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 120 %0 Book %T The Richard and Hinda Rosenthal Lectures 2003: Keeping Patients Safe -- Transforming the Work Environment of Nurses %@ 978-0-309-09441-2 %D 2004 %U https://nap.nationalacademies.org/catalog/11151/the-richard-and-hinda-rosenthal-lectures-2003-keeping-patients-safe %> https://nap.nationalacademies.org/catalog/11151/the-richard-and-hinda-rosenthal-lectures-2003-keeping-patients-safe %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 40 %X Through the generosity of the Rosenthal Family Foundation (formerly the Richard and Hinda Rosenthal Foundation), a discussion series was created to bring greater attention to some of the significant health policy issues facing our nation today. Each year a major health topic is addressed through remarks and conversation between experts in the field. The Institute of Medicine (IOM) later publishes the proceedings from this event for the benefit of a wider audience. This volume summarizes an engaging discussion on the IOM 2002 report, Keeping Patients Safe: Transforming the Work Environment of Nurses. %0 Book %A Institute of Medicine %E Page, Ann %T Keeping Patients Safe: Transforming the Work Environment of Nurses %@ 978-0-309-18736-7 %D 2004 %U https://nap.nationalacademies.org/catalog/10851/keeping-patients-safe-transforming-the-work-environment-of-nurses %> https://nap.nationalacademies.org/catalog/10851/keeping-patients-safe-transforming-the-work-environment-of-nurses %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %K Education %P 484 %X 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. %0 Book %A Institute of Medicine %T Emergency Care for Children: Growing Pains %@ 978-0-309-10171-4 %D 2007 %U https://nap.nationalacademies.org/catalog/11655/emergency-care-for-children-growing-pains %> https://nap.nationalacademies.org/catalog/11655/emergency-care-for-children-growing-pains %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 360 %X Children represent a special challenge for emergency care providers, because they have unique medical needs in comparison to adults. For decades, policy makers and providers have recognized the special needs of children, but the system has been slow to develop an adequate response to their needs. This is in part due to inadequacies within the broader emergency care system. Emergency Care for Children examines the challenges associated with the provision of emergency services to children and families and evaluates progress since the publication of the Institute of Medicine report Emergency Medical Services for Children (1993), the first comprehensive look at pediatric emergency care in the United States. This new book offers an analysis of: &#8226 The role of pediatric emergency services as an integrated component of the overall health system. &#8226 System-wide pediatric emergency care planning, preparedness, coordination, and funding. &#8226 Pediatric training in professional education. &#8226 Research in pediatric emergency care. Emergency Care for Children is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency health care providers, professional organizations, and policy makers looking to address the pediatric deficiencies within their emergency care systems. %0 Book %A Institute of Medicine %E Alper, Joe %E Hernandez, Lyla M. %T Facilitating Patient Understanding of Discharge Instructions: Workshop Summary %@ 978-0-309-30738-3 %D 2014 %U https://nap.nationalacademies.org/catalog/18834/facilitating-patient-understanding-of-discharge-instructions-workshop-summary %> https://nap.nationalacademies.org/catalog/18834/facilitating-patient-understanding-of-discharge-instructions-workshop-summary %I The National Academies Press %C Washington, DC %G English %K Health and Medicine %P 76 %X The Roundtable on Health Literacy brings together leaders from academia, industry, government, foundations, and associations and representatives of patient and consumer interests who work to improve health literacy. To achieve its mission, the roundtable discusses challenges facing health literacy practice and research and identifies approaches to promote health literacy through mechanisms and partnerships in both the public and private sectors. To explore the aspects of health literacy that impact the ability of patients to understand and follow discharge instructions and to learn from examples of how discharge instructions can be written to improve patient understanding of-and hence compliance with-discharge instructions, the Roundtable on Health Literacy held a public workshop. The workshop featured presentations and discussions that examined the implications of health literacy for discharge instructions for both ambulatory and inpatient facilities. Facilitating Patient Understanding of Discharge Instructions summarizes the presentations and discussions of the workshop. This report gives an overview of the impact of discharge instructions on outcomes, and discusses the specifics of inpatient discharge summaries and outpatient after-visit summaries. The report also contains case studies illustrating different approaches to improving discharge instructions. %0 Book %A Institute of Medicine %T Key Capabilities of an Electronic Health Record System: Letter Report %@ 978-0-309-18543-1 %D 2003 %U https://nap.nationalacademies.org/catalog/10781/key-capabilities-of-an-electronic-health-record-system-letter-report %> https://nap.nationalacademies.org/catalog/10781/key-capabilities-of-an-electronic-health-record-system-letter-report %I The National Academies Press %C Washington, DC %G English %K %K Computers and Information Technology %P 35 %X Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.