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- Culture of Safety
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- Error Reporting and Analysis 2
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- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 1
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Search results for "Audiovisual"
Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.
The near elimination of central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. Although the checklist for CLABSI prevention has been widely publicized, equally important components of the intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety culture in participating ICUs. The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success of the Michigan initiative nationwide, centered around implementation of the CUSP. The initial results, presented in this press release, indicate another remarkable success, with CLABSI rates being reduced by 40% across 1100 participating ICUs. It is notable that these reductions were accomplished even though the baseline rate of CLABSI was already lower than in prior studies. The developer of CUSP, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M in 2010.
Audiovisual > Audiovisual Presentation
Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.
Featuring an discussion with the author of a recent JAMA article, this archived webinar explored systemic causes for delays in test follow-up and offered strategies to address them.
Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.
The landmark Keystone ICU project, a statewide quality improvement initiative that used interventions grounded in safety culture and human factors engineering to improve safety in the intensive care unit, stands as one of the seminal achievements of the patient safety field. The success of the Keystone ICU project at reducing central line–associated bloodstream infections has been widely publicized, and this study reports a similar success in reducing rates of ventilator-associated pneumonia. As with the prior results, this article emphasizes that the success of the study was attributable to the multifaceted quality improvement approach used and the cultural change it engendered in participating ICUs.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Tools, Methods, and Techniques for Improving Patient Safety: Patient Safety Improvement Corps Training DVD.
Rockville, MD: Agency for Healthcare Research and Quality; 2007.
This DVD provides training modules for health care professionals regarding systems-oriented, institutional improvements in patient safety.
"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.
Dr. Berwick, President and CEO of the Institute for Healthcare Improvement, shares his insights on why health care is difficult to fix and his optimism that systems can be changed to reduce, and even eliminate, medical error.