Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety 17
- Education and Training 10
Error Reporting and Analysis
- Error Reporting 14
- Human Factors Engineering 4
- Legal and Policy Approaches 18
- Logistical Approaches 3
- Quality Improvement Strategies 27
- Research Directions 2
- Teamwork 6
- Clinical Information Systems 5
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 8
- Medication Safety 12
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 3
- Allied Health Services 1
- Internal Medicine 15
- Surgery 2
- Nursing 2
- Pharmacy 4
- Health Care Executives and Administrators 50
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 1
- Patients 5
Search results for "Book/Report"
- United States Federal Government
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. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.
Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.
Using data from the Healthcare Cost and Utilization Project, this report analyzed characteristics of weekend hospital stays and found that patients experienced delays in receiving care compared with patients admitted during the week.
Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10-281.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND Corporation; 2009. ISBN: 9780833047748.
This publication reports the results of a 2-year examination to determine the effectiveness of US efforts to improve patient safety, explore hospitals' experience with the AHRQ patient safety culture survey, and highlight trends in patient safety improvement.
Sorra J, Famloaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0030.
Measuring safety culture in health care organizations remains a key step in improving patient safety. Many hospitals use the validated Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey on Patient Safety Culture to assess safety culture at the hospital and unit levels. This report, building on 2007 and 2008 versions, presents baseline survey data from more than 600 hospitals to create benchmarks for comparison of different regions, hospital types, hospital size, respondent work areas, and staff positions. This report is the first to provide results showing change over time for 204 hospitals that submitted data more than once.
Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary Report.
Rockville, MD: Agency for Healthcare Research and Quality; February 2009. AHRQ Publication No. 090003.
This report summarizes key points and research findings from an AHRQ conference about the development and implementation of clinical triggers and targeted injury detection systems (TIDS) to identify patient safety risks and hazards.
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
This report summarizes findings from interviews with AHRQ-funded grantees who have implemented computerized provider order entry systems.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress a series of analyses with the first related to understanding the issues around hospital-based adverse events. This related and simultaneously released report identifies and describes state reporting systems and how they utilize the captured information. The report concludes that as of January 2008, 26 states had reporting systems in place, 23 states used the data to hold individual hospitals accountable, and 18 states reported using the data to promote learning and develop prevention strategies. A past AHRQ WebM&M perspective discusses the role of state reporting systems in advancing patient safety.
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
Telehealth is a rapidly expanding approach of adopting technology to deliver health care services and information that improves the quality, safety, access, efficiency, and costs of care. Although the evidence that telehealth achieves these aims is still lacking, this report outlines AHRQ's health information technology portfolio, which funded a number of programs to evaluate this promising technology and approach. The report findings are based on interviews with lead investigators. It discusses the scope of the projects funded, the technical challenges faced, the organizational and cultural issues encountered, and the opportunities ahead.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list.
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2008. ISBN: 9780833044808
This report analyzes AHRQ's patient safety activities, synthesizes results of the full RAND evaluation, and discusses the knowledge generated by funded research projects as well as how these have contributed to improvement.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; October 2008.
Consumers' perceptions of health care quality and access to information about quality have changed little since the 2006 version of this survey. Coordination of care among providers was a major concern for survey respondents, with two-thirds of those surveyed feeling that care coordination was at least a minor problem, and 22% reporting having visited a clinician who did not have access to all of their health information (including test results). Despite the growing focus on making health care quality information transparent and accessible to consumers, few respondents reported accessing information about the quality of their health plan, physician, or hospital, and even fewer reported using such information to make decisions about their care.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.