The PSNet Collection

Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities (R18).

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267.

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.

Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period closes September 30, 2021.

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Toolkit for Engaging Patients to Improve Diagnostic Safety.

Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.

Medical Office Survey on Patient Safety Culture.

Rockville, MD: Agency for Healthcare Research and Quality; October 2020.

This 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 current data submission window launched on September 1 and runs through October 20, 2021.

Toolkit to Improve Antibiotic Use in Long-Term Care.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.

Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.

Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through May 27, 2025.

Patient Safety Learning Laboratories: Advancing Patient Safety through Design, Systems Engineering, and Health Services Research (R18 Clinical Trial Optional).

Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.

This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 27, 2023.

Common Formats for Patient Safety Data Collection: Diagnostic Safety 1.0.

The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.

Measurement of diagnostic errors is an important challenge in health care. This announcement calls for the review of Common Formats for Event Reporting--Diagnostic Safety or CFER-DS, and supplies links to the draft formats for public comment. The development of a standard system for voluntary reporting of diagnostic errors to patient safety organizations will support effective data collection and measurement. The process for submitting comments is now closed.

AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus Prevention. Request for Proposal Comment.

Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.

This notice announces a call for comments on an information collection project drawing from the Comprehensive Unit-based Safety Program (CUSP). This project will support the implementation of targeted hospital-acquired infection improvement initiatives in intensive care units, long term care and surgical environments to reduce the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). The process for submitting comments is now closed.

New AHRQ Survey on Patient Safety Culture™ Diagnostic Safety Supplemental Items for Medical Offices.

Agency for Healthcare Research and Quality. June 2, 2021.

Measuring and improving safety culture are essential patient safety activities. This webinar introduced the Agency for Healthcare Research and Quality Medical Office Survey supplemental items focusing on diagnostic safety and presenters shared results from a pilot test.

Medical Office Survey: 2020 User Database Report.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

Diagnostic Safety Supplemental Items for Medical Office SOPS.

Agency for Healthcare Research and Quality.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This survey supplement examines elements contributing to time availability, testing and referrals, and provider and staff communication. The set is to be used in conjunction with the Agency for Healthcare Research and Quality's Medical Office Survey on Patient Safety Culture (MOSOPS®). The supplemental item set was released in time for the upcoming data submission window for the MOSOPS (September 1 - October 20, 2021).

Surveys on Patient Safety Culture(TM) (SOPS®) Hospital Survey 2021 User Database Reports.

Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2021. AHRQ Publications Nos. 21-0016(1.0) and 21-0017(2.0).

Establishing culture of safety is an essential component to develop high reliability organizations and ensure patient safety. The AHRQ Hospital Survey on Patient Safety Culture is a validated survey that examines organizational perceptions about safety culture ranging from communication about errors to teamwork within and across units. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The 2021 SOPS Hospital 1.0 Database Report includes 320 hospitals and 191,977 respondents, and the 2.0 Database Report includes 172 hospitals and 87,856 respondents. In both reports, areas of strength included teamwork within units and leadership, and respondents reported concerns about handoffs and transitions. The 1.0 Database Report also noted concerns about leadership expectations and actions for promoting safety, and the 2.0 Database Report noted concerns about staffing and work pace.

Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine.

Fed Register. 2021;86(51):14752-14753.

The Patient Safety and Quality Improvement Act of 2005 created a framework that supports efforts to improve patient safety and reduce the incidence of adverse events. It also requires the Secretary of the U.S. Department of Health and Human Services, in consultation with the Director of the Agency for Healthcare Research and Quality, to prepare a draft report on effective strategies for improving patient safety and encouraging the use of effective improvement strategies. The deadline for public comment on the draft report has now passed.

Using Innovative Digital Healthcare Solutions to Improve Quality at the Point of Care (R21/R33 - Clinical Trial Optional).

Rockville, MD: Agency for Healthcare Research and Quality. February 9, 2021. PA-21-164.

Digital strategies hold promise for improving point-of-care efficiency, communication, and safety. This funding opportunity will support research exploring how digital technology can be designed and implemented to improve the quality of healthcare services delivery at the point of care. Areas of interest include the use of patient-facing technologies, development of advanced analytics, and improvements in point-of-care clinical decision making.

National Healthcare Quality and Disparities Report: Chartbook on Patient Safety.

Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.

The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent update documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February 2021.

Health information technology (Health IT) presents opportunities to engage patients and families in decision making. This issue brief highlights health IT tools that can close this communication gap to engage patients in diagnosis in the emergency room. This brief is part of a publication series examining diagnostic improvement across health care.

SOPS Surveys.

Agency for Healthcare Research and Quality.

Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture and a range of content related to the successful use of the surveys. Topics covered include organizational characteristics required for successful web-based distribution of the survey and best practices for formatting, programming, and administering the surveys in a variety of environments.

National Healthcare Quality and Disparities Reports.

Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2020 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

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