Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 4
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 3
- Research Directions
- Technologic Approaches 6
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Medical Complications 1
- Medication Safety 2
- Surgical Complications 1
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Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Journal Article > Review
Caruso CC, Bushnell T, Eggerth D, et al. Am J Ind Med. 2006;49:930-942.
The authors reviewed literature and sought expert opinion to identify the reasons for and effects of long working hours, then identified research needed to pinpoint employee groups most at risk for negative consequences.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Valdez RS, Ramly E, Brennan PF. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0079-EF.
This workshop report explores why efforts to apply industrial and systems engineering (ISyE) knowledge to health care have been generally unsuccessful and suggests a research and action agenda using ISyE knowledge to create an ideal health care delivery system.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.
Journal Article > Commentary
Ricciardi R, Shofer M. J Nurs Care Qual. 2018;33:195-199.
In this commentary, Agency for Healthcare Research and Quality staff summarize how agency activities have evolved over time. The authors review AHRQ efforts to designed to understand and improve patient safety in outpatient environments, engage patients and families in care activities, and build learning communities.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.
This announcement highlights Agency for Healthcare Research and Quality funding opportunities for health services research to assess local, state, and system-level policy to address the opioid crisis, evaluate interventions to minimize opioid misuse, and understand the rapid increase in opioid-related hospitalizations.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
The introduction of information technology has transformed health care. This notice of intent from AHRQ announces an upcoming funding opportunity to support research exploring the adoption of interoperable information technologies to improve communication during transitions. The pending funding will help to refine and develop methods to assess implementation success.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Grant > Government Resource
US Department of Health and Human Services. Program Announcement No. RFA-HS-19-003.
Diagnostic error research is emerging as an area of focus in health care. This funding opportunity will support large research projects that seek to examine diagnostic processes and diagnostic errors in a variety of settings and patient populations. The deadline for submitting a letter of intent is April 22, 2019. The application due date is May 29, 2019.