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Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; March 2018.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use.
Journal Article > Study
How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
Lanham HJ, McDaniel RR, Crabtree BF, et al. Jt Comm J Qual Patient Saf. 2009;35:457-466.
This study used organizational theory approaches to analyze work relationships in primary care practices and to identify relationship factors that influenced the quality of care.
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.
Web Resource > Government Resource
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.
Agency information collection activities: Assessing the Impact of the National Implementation of TeamSTEPPS Master Training Program; comment request.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. August 27, 2013;78:52927-52929.
This notice requests comments on a proposed project to evaluate TeamSTEPPS training and implementation efforts. The comment submission process is now closed.
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.
Journal Article > Study
Wang Y, Eldridge N. Metersky ML, et al. N Engl J Med. 2014;370:341-351.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.