Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Additional Filters
1 - 20 of 40
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Rockville, MD: Agency for Health Quality and Research; June 2022.

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.

Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.

Improving diagnosis and reducing diagnostic errors are patient safety priorities. This announcement supports the development of Diagnostic Centers of Excellence focused on improving frontline diagnostician support and improving diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference standards). Applications are due by June 9, 2022.

Occupational Safety and Health AdministrationMarch 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.
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. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 

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.

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.

The Society for Post-Acute and Long-Term Care Medicine.

Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning network to share aggregated data, lessons learned, and educational opportunities to reduce medication adverse events through safe deprescribing. 

United Kingdom.

Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.

116th Congress 2d session. December 10, 2020.

The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic improvement. The ‘‘Improving Diagnosis in Medicine Act of 2020’’ outlines characteristics of a proposed Federal program to enhance agency cooperation and coordination to improve diagnosis in health care by addressing systemic weaknesses, knowledge gaps, and training issues in the workforce.

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

Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living conditions, and nursing home staff are among the most at-risk essential workers. In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established this network to prevent infections among nursing home residents and staff. All nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program that includes peer-to-peer, case-based learning and additional mentorship from local and national experts. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics. 

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.   

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019.  While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future.  In light of the COVID-19 pandemic, these findings are particularly concerning.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.