Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 7
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 3
Search results for "Book/Report"
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
Donchin Y, Gopher D, eds. New York, NY: CRC Press; 2013. ISBN: 9781466573628.
This publication uses case studies to explore human factors in health care and describes an approach to augment quality and prevent errors.
National Advisory Group on the Safety of Patients in England. London, England: Crown Publishing; August 2013.
Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.
Keogh B. London, UK: National Health Service; July 2013.
Outlining findings from an investigation into care delivered at National Health Service trusts with high mortality rates, this report details weaknesses in the organizations and recommends actions to address them.
Golden, CO: Healthgrades; 2013.
This analysis of Medicare hospitalization data from 2009–2011 highlights hospital efforts to drive safety improvement but notes that more than 280,000 preventable patient safety events occurred. The report also recognizes 379 hospitals with a Patient Safety Excellence Award for 2013.
Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447.
Despite great effort, health care organizations are still learning how to identify safety problems, especially with regard to proactively detecting latent errors before patients are harmed. Prior studies have shown that no single method can unearth all safety problems within an organization, forcing leaders to rely on multiple complementary sources of data. In this report, the authors present a framework for developing a comprehensive picture of safety at the organizational level. Drawing on principles used by high reliability organizations in other industries, the framework encompasses five domains of safety: past harm (retrospectively identifying safety issues, such as through incident reports), reliability (ensuring adherence to appropriate processes of care), sensitivity to operations (prospectively identifying safety problems), anticipation and preparedness (maintaining safety culture and using checklists to avert common complications), and learning from safety events. The lead author of the report, Prof. Charles Vincent, was interviewed by AHRQ WebM&M in 2012.
Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.
This report describes a collaborative effort to engage public hospitals in patient safety work and highlights its successful outcomes.
Kingston-Riechers J, Ospina M, Jonsson E, Childs P, McLeod L, Maxted JM. Edmondton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541273.
This report analyzed patient safety in Canadian primary care practice to identify themes, priorities, gaps in research, and opportunities for improvement.
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.
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.