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Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
This special issue highlights an AHRQ-funded symposium on the role of simulation in medical education and covers topics such as teamwork training and skill improvement.
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. Medical offices that have administered the survey can submit data to AHRQ from September 3, 2019 to October 21, 2019.
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Pediatric Quality Indicators focus on quality of care inside hospitals and identify potentially avoidable hospitalizations among children.
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.
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.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.
This funding program will support research demonstration projects that explore systemic strategies to enhance medication safety. The submission process for the program is now closed.
Special or Theme Issue
Making Health Care Safer: A Critical Review of Modern Evidence Supporting Strategies to Improve Patient Safety.
Shekelle PG, Pronovost PJ, Wachter RM, Rao JK, Mulrow CD, eds. Ann Intern Med. 2013;158(5 Pt 2):365-440.
In 12 years since the seminal AHRQ Making Health Care Safer report was issued, research in the patient safety field has grown considerably, yielding a much stronger evidence base for preventing some types of errors. However, the literature also shows examples of many interventions that were strongly touted initially, but whose early successes could not be replicated. The systematic reviews in this special supplement—released in conjunction with the new AHRQ report, Making Health Care Safer II, from which these reviews are derived—critically examine the evidence supporting 10 patient safety practices, including methods to prevent particularly common adverse events such as diagnostic errors, adverse events after hospital discharge, and medication errors. Even after a decade of research into patient safety strategies, relatively few strategies are strongly supported by evidence. Thus, this supplement highlights "the continuing tension between needing to improve care and knowing how to do it." By explicitly considering the role of intervention cost, ease of implementation, and the effect of context on intervention success, the reviews attempt to help policymakers and safety professionals make decisions around how to improve safety in the face of limited or equivocal evidence.
Journal Article > Review
McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Ann Intern Med. 2013;158(5 Pt 2):381-389.
Conducted as part of the AHRQ Making Health Care Safer II report, this article reviews the expanding research base in diagnostic error prevention. Several promising systems-based interventions were identified that seemed to reduce diagnostic errors, although the strength of evidence for these strategies was low.
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.
Grant > Grant Announcement
Patient Safety Learning Laboratories: Innovative Design and Development to Improve Healthcare Delivery Systems (P30).
Rockville, MD: Agency for Healthcare Research and Quality; February 5, 2015. Funding Opportunity Announcement No. RFA-HS-15-001.
This funding program seeks to support professional networks committed to developing approaches to reduce patient safety hazards. The process for submitting letters of intent for the program is now closed.
Tools/Toolkit > Government Resource
The Patient Education Materials Assessment Tool (PEMAT) and User's Guide: An Instrument to Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials.
Rockville, MD: Agency for Healthcare Research and Quality; October 2013.
This tool offers a method to assess patients' ability to understand and use education materials, including audiovisual and print formats.
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.
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.