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Sorra J, Famolaro T, Yount ND, Smith SA, Wilson S, Liu H. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
This annually released report of the AHRQ Hospital Survey on Patient Safety Culture comparative database presents benchmarking data for safety culture from 653 hospitals nationwide, including trending data on changes in safety culture perception over time for more than 300 hospitals. The full report contains detailed comparative data for various hospital characteristics (type and size) and respondent characteristics (work areas, staff positions, and direct patient contact). Areas of strength included teamwork, leadership, and continuous improvement, all of which have been emphasized in patient safety efforts. However, as in prior reports, concerns were voiced about the safety of handoffs. Most respondents reported that staffing was suboptimal for supporting patient safety, and a non-punitive approach to errors remains elusive for most hospitals.
Journal Article > Commentary
Kronick R, Arnold S, Brady J. JAMA. 2016;316:489-490.
The publication of To Err Is Human in 1999 drew national attention to the issue of patient safety and is often credited with catalyzing widespread efforts to reduce health care–related harm. At the time of the report's publication, central line–associated bloodstream infections (CLABSIs) were considered unpreventable. However, subsequent public reporting programs and the trend toward nonpayment for preventable harm have led not only to a significant reduction in CLABSIs, but a decrease in other types of hospital-acquired conditions as well. This directly translates into improved patient outcomes and reduced health care costs. This commentary highlights progress made in patient safety and suggests that future efforts should focus on improving the measurement of adverse events and mitigating diagnostic error. A past PSNet perspective discussed the evolution of patient safety as it relates to surgery.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
Meeting/Conference > Government Resource
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
Journal Article > Study
Advancing perinatal patient safety through application of safety science principles using health IT.
Webb J, Sorensen A, Sommerness S, Lasater B, Mistry K, Kahwati L. BMC Med Inform Decis Mak. 2017;17:176.
AHRQ's Safety Program for Perinatal Care used a multifaceted approach based on the comprehensive unit-based safety program to improve safety culture and perinatal outcomes at 46 hospitals. In this study, investigators conducted structured interviews to evaluate how participating hospitals used health information technology to enable implementation of the program. A variety of uses for health IT were described, including integration of checklists and standardized handoff tools into the electronic health record.