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Legislation/Regulation > Congressional Testimony
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations.
Testimony before the Permanent Subcommittee on Investigations of the Senate Committee of Governmental Affairs, 108th Cong, 1st Sess (June 11, 2003) (statement of Carolyn M. Clancy, MD).
In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.
Journal Article > Study
Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. J Gen Intern Med. 2005;20:686-691.
This retrospective cohort study conducted reviews of both inpatient and outpatient medical records to determine the incidence and types of errors identified. Using a random sample of more than 600 patients from a Veterans Affairs health care system, investigators discovered nearly 3000 errors. The large majority of errors were attributed to the underuse of care, particularly in patients suffering from chronic diseases. The authors conclude that safety efforts and ongoing quality improvement should focus as much on errors of omission as they do on errors of commission.
Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.
Washington, DC: United States Government Accountability Office; 2005. Report No. GAO-06-117.
This report shares findings from a 5-year review of nursing home quality and safety, which revealed inconsistencies in state surveys that affect the government's ability to adequately address problems in care.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.