Narrow Results Clear All
- Commentary 57
- Review 15
- Study 119
- Slideset 3
- Book/Report 147
- Regulation 12
- Newspaper/Magazine Article 24
- Newsletter/Journal 5
- Special or Theme Issue 14
- Glossary 2
- Toolkit 46
- Forum 1
- Award 2
- Bibliography 1
- Clinical Guideline 4
- Grant 27
- Meeting/Conference 27
- Press Release/Announcement 86
- Communication Improvement 108
- Culture of Safety 78
Education and Training
- Simulators 10
- Students 1
Error Reporting and Analysis
- Never Events 12
- Error Reporting 94
Human Factors Engineering
- Checklists 10
Legal and Policy Approaches
- Regulation 19
- Logistical Approaches 26
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 23
- Research Directions 11
- Specialization of Care 13
- Teamwork 29
- Clinical Information Systems 43
- Transparency and Accountability 1
- Device-related Complications 52
- Diagnostic Errors 22
- Discontinuities, Gaps, and Hand-Off Problems 46
- Drug shortages 4
- Fatigue and Sleep Deprivation 10
- Identification Errors 4
- Interruptions and distractions 4
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 123
- MRI safety 2
- Nonsurgical Procedural Complications 12
- Overtreatment 2
- Psychological and Social Complications 12
- Second victims 1
- Surgical Complications 43
- Transfusion Complications 3
- Allied Health Services 1
- Geriatrics 27
- Primary Care 30
- Internal Medicine 175
- Nursing 32
- Pharmacy 82
- Family Members and Caregivers 8
- Health Care Executives and Administrators 470
Health Care Providers
- Nurses 49
- Pharmacists 38
- Physicians 72
Non-Health Care Professionals
- Educators 32
- Engineers 18
- Media 1
- Patients 100
- Australia and New Zealand 1
- Europe 1
United States of America
United States Federal Government
- Department of Health and Human Services (HHS)
- United States Federal Government
- United States of America
Search results for ""
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Evidence Report/Technology Assessment: Number 74. Rockville, MD: Agency for Healthcare Research and Quality; March 2003. AHRQ Publication No. 03-E024.
This report summarizes existing scientific evidence on the role health care working conditions play in patient safety efforts.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
GOLD is a searchable database of grants funded by the Agency for Healthcare Research and Quality (AHRQ).
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2012. AHRQ Publication No. 01-0040d.
This AHRQ brochure provides practical advice for patients facing non-emergent surgery, to help them be generally informed about the procedure, aware of the risks, and prepared to contribute to the safety of their experience.
Legislation/Regulation > Government Resource
US Food and Drug Administration, HHS. Final rule. Fed Regist. February 26, 2004;69(38):9119-9171.
The US Food and Drug Administration (FDA) requires certain human drug and biological product labels to contain bar codes. The rule aims to reduce the number of medication errors by allowing health care professionals to use bar code scanning equipment for necessary verification. This protects against an incorrect drug administration. Effective date: April 26, 2004.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; October 2000. AHRQ Publication No. 01-0004.
This guide offers information and resources to allow consumers to understand quality health care. The site is organized to read page by page or to immediately browse to specific sections. Content areas include health care quality, quality measurement and tools, health care decision making, clinical trials, and a directory of resources.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality's (AHRQ) online journal and forum on patient safety and health care quality. The site features expert analysis and discussion of anonymously submitted cases where an error was described. The site also includes interactive learning modules ("Spotlight Cases") and forums for online discussion. Continuing Medical Education (CME) and Continuing Education (CE) credit is available.
Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication 01-0020.
Adverse drug events (ADEs) result in more than 770,000 annual injuries and deaths with significant resulting costs. Hospitals can reduce this burden by promoting system changes to better detect and prevent ADEs. Successful approaches are summarized.
Web Resource > Forum
US Food and Drug Administration.
Joining this forum will assist subscribers in keeping aware of safety alerts issued by the U.S. Food and Drug Administration (FDA) resulting from MedWatch reports.
Journal Article > Commentary
Clancy CM, Scully T. Health Aff (Millwood). 2003;22:113-115.
This commentary, written by leadership from the Agency for Healthcare and Research Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), shares the vision of how patient safety will be achieved through targeted federal initiatives. The authors discuss the shifting paradigm that must result in the way our health systems understand, learn from, and prevent errors. They discuss several strategies already in place to support the mission of their respective agencies "to support research, information, and partnerships to ensure that all Americans receive high-quality, safe, and efficient health care."
Journal Article > Study
Roberts R, Rodriguez W, Murphy D, Crescenzi T. JAMA. 2003;290:905-911.
Journal Article > Study
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
Zhan C, Miller MR. JAMA. 2003;290:1868-1874.
Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.
Rockville, MD: United States Pharmacopeial Convention, Inc.; 2004.
This report provides an analysis of more than 235,000 records submitted by 570 participating facilities to Medmarx and also provides trend analyses for records submitted between 1999 and 2003. The report contains three technology-focused special topics: computer entry, computerized prescriber order entry—analysis performed in collaboration with the Agency for Healthcare Research and Quality (AHRQ)—and automated dispensing devices.
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.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Meeting/Conference > Meeting/Conference Proceedings
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).
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.
Audiovisual > Audiovisual Presentation
U.S. Food and Drug Administration, Rockville, MD.
FDA Patient Safety News is a televised series for health care personnel. The monthly series runs on satellite broadcast networks targeting hospitals and other medical facilities across the country. It features information on new drugs and medical devices, on U.S. Food and Drug Administration (FDA) safety notifications and product recalls, and on ways to protect patients when using medical products.
Jt Comm J Qual Saf. 2004;30:653-680.
Special issue highlighting the winners of the 2004 John Eisenberg Award, which included Lucian Leape, MD; Peter Pronovost, MD; Robert Wachter, MD, and Kaveh Shojania, MD; Major Danny Jaghab; and the University of Pittsburgh Medical Center McKeesport, McKeesport, Pennsylvania.
Kruzikas DT, Jiang HJ, Remus D, Barrett ML, Coffey RM, Andrews RA. Rockville, MD: Agency for Healthcare Research and Quality; September, 2004. AHRQ Publication No. 04-0056.
This Fact Book examines a critical area of health care quality: potentially preventable hospitalizations. Higher rates of "preventable hospitalizations" may identify areas for improvement within primary and preventive care.
Plsek P. Paper presented at: Accelerating Quality Improvement in Health Care Strategies to Speed the Diffusion of Evidence-Based Innovations; January 27-28, 2003; Washington, DC.
In discussing the complexities of health care, the author provides insights into how this complexity creates challenges to the blunt end process of medicine. This impacts health care's ability to spread and support innovation.