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- Communication Improvement 4
- Culture of Safety
Education and Training
- Students 1
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Research Directions 2
- Teamwork 7
- Technologic Approaches 6
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Medical Complications 4
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 1
- Transfusion Complications 1
Search results for ""
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.
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 2005. AHRQ Publication No. 05-P003-3.
This program brief summarizes patient safety research projects funded by the Agency for Healthcare Research and Quality (AHRQ) since 2001.
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.
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.
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.
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.
Audiovisual > Audiovisual Presentation
Washington, DC: US Department of Health and Human Services; May 2011.
This training program explores how to create a culture of safety and prevent health care–associated infections.
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.
Grant > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09-P013-4-E.
This announcement highlights projects funded by the Agency for Healthcare Research and Quality to reduce incidence of health care–associated infections.
Journal Article > Review
Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Ann Intern Med. 2013;158(5 Pt 2):369-374.
This systematic review—part of the AHRQ Making Health Care Safer II report—found some evidence that interventions, such as teamwork training, executive walk rounds, and structured communications approaches, can improve safety culture, especially when bundled together as a multicomponent intervention.
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
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019;45:231–240.
Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.