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Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The RAND Corporation;2005. ISBN: 0833037870.
The authors report on the history of Agency for Healthcare Research and Quality's (AHRQ) involvement in patient safety, recap AHRQ's activities through September 2003, and provide suggestions for future actions. This document is the first of four yearly reports funded by AHRQ to assess their work.
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).
Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The Rand Corporation; 2007. ISBN: 9780833041487.
This report is the second installment of a series commissioned to evaluate the success of the Agency for Healthcare Research and Quality's patient safety agenda and related programs.
Tools/Toolkit > Government Resource
Jacobson KL, Gazmararian JA, Kripalani S, McMorris KJ, Blake SC, Brach C. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 07-0051.
This AHRQ-funded publication provides a tool to help organizations identify health literacy issues, as well as methods for implementing an action plan drawn from assessment results.
Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.
This publication reports recommendations from a focus group exploring the utility of health information technology in enhancing quality measurement and discusses how the data can be used to improve care.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.