Narrow Results Clear All
- Commentary 115
- Review 24
- Study 72
- Slideset 2
- Book/Report 35
- Legislation/Regulation 53
- Newspaper/Magazine Article 77
- Special or Theme Issue 5
- Toolkit 10
- Web Resource 46
- Clinical Guideline 13
- Grant 2
- Meeting/Conference 2
- Press Release/Announcement 15
Communication between Providers
- Sbar 2
- Communication between Providers 39
- Culture of Safety 28
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 33
Human Factors Engineering
- Checklists 19
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 12
- Policies and Operations 3
Quality Improvement Strategies
- Benchmarking 10
- Reminders 10
- Research Directions 2
- Specialization of Care 12
- Teamwork 16
- Clinical Information Systems 25
- Device-related Complications 42
- Diagnostic Errors 12
- Discontinuities, Gaps, and Hand-Off Problems 25
- Drug shortages 3
- Failure to rescue 1
- Fatigue and Sleep Deprivation 8
- Identification Errors 10
- Inpatient suicide 1
- Interruptions and distractions 3
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 126
- MRI safety 3
- Nonsurgical Procedural Complications 16
- Overtreatment 2
- Psychological and Social Complications 10
- Surgical Complications 36
- Ambulatory Care 48
- Hospitals 230
- Long-Term Care 6
- Outpatient Surgery 6
- Patient Transport 1
- Psychiatric Facilities 2
- Allied Health Services 4
- Dentistry 1
- Geriatrics 10
- Obstetrics 21
- Radiology 10
- Internal Medicine 99
- Nursing 33
- Palliative Care 1
- Pharmacy 66
- Family Members and Caregivers 5
- Health Care Executives and Administrators 262
Health Care Providers
- Nurses 92
- Pharmacists 57
- Physicians 112
Non-Health Care Professionals
- Media 1
- Patients 29
- Asia 1
- Australia and New Zealand 3
- Europe 4
- Canada 2
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 42
- United States Federal Government 53
Search results for ""
This website is a practical resource to review existing clinical practice guidelines in a centralized location. Key components of the site include links to full-text guidelines and an assessment function that explores the rigor and trustworthiness of each document. This website was built by the team that developed and maintained the AHRQ National Guideline Clearinghouse, which is no longer available.
Web Resource > Multi-use Website
New York Department of Health, Empire State Plaza, Albany, NY 12237.
The Center's efforts for patient safety are highlighted, including New York's Patient Occurrence Reporting and Tracking System, Clinical Guideline development, and a state patient safety awards program.
Tools/Toolkit > Toolkit
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.
Journal Article > Study
Collard HR, Saint S, Matthay MA. Ann Intern Med. 2003;138:494-501.
Health care–associated infections (HAIs) are a common adverse event in hospitalized patients and an increasing source of study for preventive strategies. Ventilator-associated pneumonia (VAP) is one of the four most common HAIs along with catheter-related bloodstream infection, catheter-associated urinary tract infection, and surgical site infection. This systematic review provides a series of recommendations to reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather than H2-antagonists, and aspiration of subglottic secretions in select patient populations. The authors point out that while many studies highlight the success of preventive strategies, no randomized trial has evaluated the effects of combining the preventive practices as an additive bundle or checklist.
Tools/Toolkit > Toolkit
Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.
A compendium of risk assessment tools to assist in the prevention of medication errors. The tools emphasize the importance of a multidisciplinary approach to managing risk with key sections focusing on physicians, nurses, pharmacists, risk managers, and administrators.
Tools/Toolkit > Government Resource
Atlanta, GA: U.S. Centers for Disease Control and Prevention.
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC) strategy to promote patient safety by reducing infections in health care settings. The site includes fact sheets, a press kit, and other materials to help implement the guidelines.
Polovich M, Blecher CS, Glynn-Tucker EM, McDiarmid M, Newton SA. Pittsburgh, PA: Oncology Nursing Society (ONS); 2003.
This guideline provides recommendations to enhance the safe delivery of high-risk medications. Topics include assessing occupational exposure risks, engineering controls, work practice controls, safety measures, drug administration, and postadministration practices.
Grant > Fact Sheet/FAQs
Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; March 2004. AHRQ Publication No. 04-P013.
In fiscal year 2004, the Agency for Healthcare Research and Quality (AHRQ) awarded nearly $4 million in Patient Safety Challenge Grants to support 13 new practice implementation projects. AHRQ challenged the health care community and other organizations to develop innovative solutions for the harm resulting from medical errors. The tools and procedures that emerged from these projects advanced the translation of research into clinical practice to support the agency's commitment to a medical culture grounded in safety and quality.
ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred because of a misinterpreted decimal point. The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5 mg of the drug. The order did not include a zero before the decimal point, and the nurse filling the order overlooked the omission. The child suffered a cardiac arrest and died. The case illustrates the importance of clearly communicating information about medications.
National Quality Forum. Washington, DC: National Quality Forum; 2007.
The National Quality Forum used expert consensus and evidence review to identify 30 health care ''safe practices'' that should be consistently utilized to minimize the risk of harm to patients. Originally disseminated in 2003 and updated in 2006, these practices are organized into seven primary content areas: creating a culture of safety, matching health care needs with service delivery capability, facilitating information transfer and clear communication, preventing healthcare-associated infections, honoring patient wishes for informed content and disclosure, increasing safe medication use, and adopting safe practices in specific clinical care settings or for specific processes of care. Each practice is presented in capsule form with detailed specifications, applicable setting of care, supporting evidence, and additional background.
Eichhorn JH, Cooper JB, Cullen DJ, Philip JH, Maier WR, Seeman RG. JAMA. 1986;256:1017-1020.
To proactively devise a patient safety strategy for anesthesia, the authors of this article summarized a series of mandatory standards implemented at Boston's nine component teaching hospitals. The authors discuss the detailed process that led to the highlighted standards, including the need to balance physician autonomy with the larger goal of improving patient care. One of the objectives from their efforts was to demonstrate the applicability of the process and to counter increases in anesthesia-related malpractice claims. They suggest the need for both a strong commitment to leadership and the development of a process to foster similar standards and improvements throughout the country.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. October 6, 2004;(32):1-3.
This alert provides recommendations for minimizing the risk of anesthesia awareness.
Journal Article > Study
Hanna D, Griswold P, Leape L, Bates DW. Jt Comm J Qual Patient Saf. 2005;31:68-80.
Part of a special theme issue on Communicating Critical Test Results, this article outlines a series of safe practice recommendations, building on an initiative organized by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. The authors provide context to their recommendations and then offer a detailed table that walks users the suggested practices. Related appendices provide rationale and operating definitions for communicating critical test results as well as a ''starter set'' for specific values and interpretations. A previous AHRQ WebM&M commentary addressed the issue of communication surrounding critical laboratory values.
Tools/Toolkit > Fact Sheet/FAQs
National Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. AHRQ Publication No. 04-P025.
This fact sheet presents 30 safe practices that can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all applicable health care settings to reduce the risk of harm to patients. The practices are derived from a 2003 consensus report developed by the National Quality Forum.
Journal Article > Commentary
Bright L. Home Healthc Nurse. 2005;23:29-36.
The author presents a program of assessment, education, and follow-up that successfully reduced fall-related injuries.
Journal Article > Commentary
Friedman MM. Home Healthc Nurse. 2005;23:243-253.
This article reviews the National Patient Safety Goal (NPSG) for 2005 on look-alike/sound-alike medications and makes suggestions for implementation in home care and hospice organizations.
Journal Article > Review
Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.
Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.
This review examines the literature on coordination of care and its effectiveness to better understand how a generalist operates in an increasingly complex health care delivery system. The authors present six key recommendations. These include the need for greater evidence to substantiate the value of care coordination in improving health outcomes; a belief that a generalist's practice represents an effective hub for coordinating care in most patients; and that improved communication and coordination among generalists, specialists, patients, and their family members must be fostered. The authors advocate for greater emphasis on teamwork, increased education about effective communication and collaboration skills, and wider adoption and application of medical informatics.
Journal Article > Study
Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
Larson EL, Cimiotti J, Haas J, et al. Arch Pediatr Adolesc Med. 2005;159:377-383.
Recent guidelines from the Centers for Disease Control and Prevention (CDC) recommend the use of alcohol-based hand sanitizers rather than traditional hand washing. This clinical trial compared these strategies on patient infection rates, nurses' skin conditions, and microbial counts in neonatal intensive care units. Adjusted results showed no difference in patient infection rates or microbial counts, but skin condition was improved using the alcohol-based product. The discussion compares these findings with existing research and the confounding factors associated with measured infection rates. The authors recommend adopting the CDC recommendations as a system-based method to improve hand hygiene practices.
Journal Article > Review
Glick TH. Neurologist. 2005;11:140-149.
The author reviews data on errors in neurology and identifies key areas for minimizing medical error in this specialty: accurate and timely diagnosis, effective information transfer, and patient safety education.