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- Communication Improvement 1
- Culture of Safety
- Education and Training 5
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Research Directions 2
- Teamwork 6
- Technologic Approaches 2
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Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.
Wachter and Shojania adapted many of the cases they previously published in the academic literature, some cases previously described in the lay literature (eg, the Duke transplant mix-up and the death of Betsy Lehman at Dana-Farber Cancer Institute), and other cases never previously reported to provide a dramatic account of medical errors and the field of patient safety. Dr. Lucian Leape wrote that Internal Bleeding "shows how cognitive psychology and human factors engineering provide the way out by shifting attention from blaming individuals to fixing faulty systems." The book, now in its fourth printing, continues to be a popular choice for anyone with an interest in patient safety.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.
Legislation/Regulation > Federal Legislation
Pub L No. 109-41.
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations. The bill, signed into law July 29, 2005, provides legal protection of information voluntarily reported to patient safety organizations (PSOs). This protection helps encourage institutions and individuals to more freely report incidents, concerns, and near misses. PSOs can receive reports on quality and safety from any health care provider, including hospitals, doctors' offices, nursing homes, and ambulatory surgery centers. The federal government has developed and maintains the voluntary reporting system, working with PSOs to analyze data submitted through the system. An annual quality report is released based on this analysis. Dr. William B. Munier discussed the development and implementation of PSOs in an AHRQ WebM&M interview.
Journal Article > Study
Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.
Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM Jr. J Am Coll Surg. 2007;205:778-784.
Hospitals are urged to measure their safety culture through the use of one of several validated surveys that assess teamwork and organizational attitudes toward safety. Although several such surveys exist, evidence linking survey responses to improved patient outcomes is lacking. This AHRQ-funded study assessed the relationship between safety culture (as measured by the Safety Attitudes Questionnaire) and clinical outcomes in surgical patients, and found no clear relationship between perceived safety culture and risk-adjusted morbidity and mortality. However, reduced morbidity correlated with higher ratings of communication within surgical teams. This finding supports prior research that implicated communication failures as a cause of safety problems in surgery.
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.
Journal Article > Study
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Classic studies have demonstrated that operating rooms are rife with communication and teamwork problems, and suboptimal teamwork has been linked to poor postoperative patient outcomes. In this rigorously designed study, surgical teams at 74 Veterans Affairs (VA) hospitals underwent teamwork training through the VA's Medical Team Training program. The training also included implementation of preoperative and postoperative checklists. The teamwork training was associated with a striking reduction in mortality compared to other VA hospitals that had not yet implemented the program, and a dose–response effect was also evident, with continuing training resulting in further reductions in mortality. An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based evaluation of a safety intervention, and stresses that addressing teamwork and safety culture are as essential to improving safety as technical and procedural interventions such as checklists.
Journal Article > Study
Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.
Health care–associated infections remain one of the most common preventable adverse events in hospitals, despite some successes at reducing rates of specific infections. Preventing infections caused by methicillin-resistant Staphylococcus aureus (MRSA) remains a difficult problem, as studies of prevention techniques have reached conflicting results. This large-scale study of an MRSA prevention bundle implemented in the Veterans Affairs system found that a multifaceted approach including universal screening, contact isolation precautions, and an emphasis on infection control as part of safety culture resulted in a significant reduction in MRSA infections in both intensive care and ward patients. Although the overall incidence of hospital-acquired MRSA infections has been decreasing nationwide, the effects of these infections can be devastating—as vividly described in this AHRQ WebM&M commentary.
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.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Journal Article > Study
Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2016 Jan 7; [Epub ahead of print].
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.