Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 4
- Education and Training 4
- Error Reporting and Analysis 7
- Human Factors Engineering 4
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 13
- Specialization of Care 2
- Technologic Approaches 2
- Device-related Complications 6
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications
- Medication Safety 4
- Surgical Complications 2
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Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Rockville, MD: Agency for Healthcare Research and Quality. June 20, 2007.
This podcast discusses the importance of handwashing to reduce infections in hospitals as well as how consumers can help improve clinician compliance.
10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs.
Rockville, MD: Agency for Healthcare Research and Quality; February 19, 2009.
This announcement highlights a program in 10 states that will test methods of reducing central-line–associated blood stream infections in hospital intensive care units.
Journal Article > Study
Parente ST, McCullough JS. Health Aff (Millwood). 2009;28:357-360.
Despite widespread interest in the implementation of health information technology (HIT) and a systematic review demonstrating its positive effects on clinical outcomes, use of HIT remains limited. This AHRQ-funded study focused on the relationship between information technology implementation and patient safety by examining the incidence of selected patient safety indicators (PSIs) after implementation of HIT. Modest but significant improvements in some PSIs, including health care–associated infections, were associated with HIT implementation, corroborating the results of a prior study. The study did not assess whether specific elements of HIT, such as computerized provider order entry, were more effective at preventing errors.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
For health care providers and consumers, this Web site features information, tools, and resources on health care–associated infections (HAIs). AHRQ-funded research and initiatives to reduce HAIs are also highlighted.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
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.
Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.
The near elimination of central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. Although the checklist for CLABSI prevention has been widely publicized, equally important components of the intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety culture in participating ICUs. The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success of the Michigan initiative nationwide, centered around implementation of the CUSP. The initial results, presented in this press release, indicate another remarkable success, with CLABSI rates being reduced by 40% across 1100 participating ICUs. It is notable that these reductions were accomplished even though the baseline rate of CLABSI was already lower than in prior studies. The developer of CUSP, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M in 2010.
Journal Article > Study
Encinosa WE, Bae J. Inquiry. Winter 2011/2012;48:288-303.
Tools/Toolkit > Government Resource
Boston University School of Public Health. Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 120082EF.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Rockville, MD: Agency for Healthcare Research and Quality; November 3, 2010. Publication No. NOT-HS-11-002.
This announcement describes funding opportunities for research on health care–associated infections.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.
Special or Theme Issue
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.
Special or Theme Issue
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.
Articles in this special issue explore evidence developed from an AHRQ-funded initiative to reduce health care–associated infections (HAIs). Researchers examine epidemiological issues, disparities in HAI rates, quality improvement efforts, assessment tools, and how antibiotic stewardship programs influence HAI prevention and research.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.