Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.

The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in August 2023.

Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.

Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.

This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Community Pharmacy Survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies.

Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing and a tendency to blame individuals for problems. This website hosts the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey along with additional materials to assist organizations in using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient safety in a nursing home and report the results. The resource provides guidance on topics such as data collection, data organization, survey forms, and nursing home staff selection. The 2022 data collection period is now closed.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.

This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. 

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The release of the Workplace Safety Supplemental Item Set for use in conjunction with the AHRQ Hospital Survey helps hospitals assess how their workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The data submission window for 2023 is open until September 23.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication. The Diagnostic Safety Supplemental Item Set was released in time for the scheduled Fall 2021 MOSOPS data submission.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.

This website provides a report and data repository representing medical offices that administered the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey. Insights on safety culture reflect practices from 1,475 medical offices and more than 18,000 respondents. The current data submission deadline is September 22, 2023.

Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk. 

Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.

Organizational culture can affect the use of tools and processes implemented to improve safety. This release of the Health Information Technology Patient Safety Supplemental Item Set to be used in conjunction with the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey can help organizations explore how culture affects the use of health information technology. Included with the data set is a report of initial results regarding its use in the field.