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- Culture of Safety
Education and Training
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- Error Reporting and Analysis 2
- Quality Improvement Strategies 1
- Teamwork 3
- Technologic Approaches 2
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 1
- Medication Safety 2
- Psychological and Social Complications 1
- Transfusion Complications 1
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Audiovisual > Meeting/Conference Proceedings
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Journal Article > Study
Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.
Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
Teamwork training programs have resulted in some notable successes, but many other attempts have failed to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in durable provider behavior change. In this AHRQ-funded study, the TeamSTEPPS training program was introduced in two intensive care units (one pediatric and one adult surgical), after meticulous preparatory planning that emphasized the utility of the training for frontline care providers, engaged higher-level support for the effort, and established clear metrics for effectiveness. The program resulted in improvement in directly observed team behaviors and measures of safety culture, and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork training interventions in the context of efforts to develop high reliability organizations.
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.
Journal Article > Study
Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.
Gampetro PJ, Segvich JP, Jordan N, Velsor-Friedrich B, Burkhart L. J Patient Saf. 2019 Mar 29; [Epub ahead of print].
Measuring hospital safety culture is supported by the Agency for Healthcare Research and Quality (AHRQ). Although the relationship between a strong safety culture and improved outcomes for patients is not well established in existing literature, developing a sound safety culture is considered important for patient safety. In this cross-sectional study using data from the AHRQ Survey on Hospital Patient Safety Culture, researchers sought to understand the perceptions of pediatric hospital safety culture among interprofessional health care providers working at 287 pediatric hospitals or units. In keeping with prior research, they found that perceptions of safety culture among pediatric professionals, including nurses, physician assistants/nurse practitioners, physicians, and hospital administrators, varied both within hospitals and units. The authors identified safety culture dimensions that could be targeted for improvement and determined that all four professional groups perceived a punitive work culture. A past PSNet perspective emphasized the importance of establishing a culture of safety.