Narrow Results Clear All
- Study 2
- Slideset 1
- Book/Report 1
- Newspaper/Magazine Article 1
- Special or Theme Issue 1
- Toolkit 2
- Web Resource 6
- Grant 1
- Meeting/Conference 2
- Communication Improvement 3
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis
- Legal and Policy Approaches 2
- Quality Improvement Strategies 1
- Teamwork 2
- Technologic Approaches 2
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 2
- Medication Safety 2
- Psychological and Social Complications 1
- Transfusion Complications 1
Search results for ""
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.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.
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
Garbutt J, Brownstein DR, Klein EJ, et al. Arch Pediatr Adolesc Med. 2007;161:179-185.
Though medical errors are common in pediatric patients, to date few studies have examined pediatricians' attitudes toward errors. This AHRQ-funded study surveyed pediatric residents and attending physicians regarding their experiences with reporting medical errors. The majority of physicians had direct experience with errors and supported disclosing errors to patients and their parents, but only a minority had disclosed a serious error. Respondents expressed dissatisfaction with current means of reporting errors (eg, incident reporting systems) and expressed a desire for formal training in error disclosure. These findings are similar to those previously reported in physicians caring for adult patients.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 23, 2010.
This issue features successful patient safety innovations pertaining to disclosure, multidisciplinary patient safety conferences, and proactive reporting.
Journal Article > Study
Schneider AK, Brinsley-Rainisch KJ, Schaefer MK, Camilli T, Perz JF, Cochran RL. J Patient Saf. 2013;9:8-12.
Tools/Toolkit > Government Resource
Atlanta, GA: Centers for Disease Control and Prevention; June 6, 2013.
This toolkit provides guidance and resources to help organizations inform patients about infection control lapses.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Full disclosure programs have shown to be effective mechanisms for early resolution of adverse events. This article reveals one early adopter's experience with full disclosure and provides insights from the architects of the program to guide others in implementing similar strategies and spread success associated with the approach.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, and teaching materials, and it has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.
Audiovisual > Audiovisual Presentation
Health Services Research and the Health Research and Educational Trust. March 2, 2017.
Communication-and-resolution programs emphasize transparency and respect in discussions with patients and families following an adverse event. This webinar highlighted AHRQ-funded research and programs that explored the impact of communication-and-resolution programs and other strategies that focus on improving patient safety and reducing liability. Researchers from a recent special issue devoted to this work were featured speakers.