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Search results for ""
Tufts-New England Medical Center, Tufts University School of Medicine, and Harvard University: Center for Quality Assessment & Improvement in Mental Health; 2011.
This website provides a searchable database of process measures for quality assessment and improvement in mental health and substance abuse care. It includes more than 300 measures with specifications drawn from developer source materials.
Legislation/Regulation > Congressional Testimony
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations.
Testimony before the Permanent Subcommittee on Investigations of the Senate Committee of Governmental Affairs, 108th Cong, 1st Sess (June 11, 2003) (statement of Carolyn M. Clancy, MD).
In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2003.
This web-accessible database provides access to evidence-based quality measures and measure sets. The mission of the National Quality Measures Clearinghouse (NQMC) is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further their dissemination, implementation, and use in order to inform health care decisions.
This website is a practical resource to review existing clinical practice guidelines in a centralized location. Key components of the site include links to full-text guidelines and an assessment function that explores the rigor and trustworthiness of each document. This website was built by the team that developed and maintained the AHRQ National Guideline Clearinghouse, which is no longer available.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Grant > Fact Sheet/FAQs
Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; March 2004. AHRQ Publication No. 04-P013.
In fiscal year 2004, the Agency for Healthcare Research and Quality (AHRQ) awarded nearly $4 million in Patient Safety Challenge Grants to support 13 new practice implementation projects. AHRQ challenged the health care community and other organizations to develop innovative solutions for the harm resulting from medical errors. The tools and procedures that emerged from these projects advanced the translation of research into clinical practice to support the agency's commitment to a medical culture grounded in safety and quality.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, and the Harvard School of Public Health; November 2004.
Five years after the Institute of Medicine's landmark report on medical errors, this survey assessed Americans' perceptions about the quality of health care, their awareness and reported usage of information in making their health care choices, and their experiences with their health care providers. A summary of the findings is provided, as well as a Webcast featuring experts discussing the survey results.
Journal Article > Study
Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. J Biomed Inform. 2005;38:189-199.
Electronic medical records offer opportunities to generate automatic clinical reminders, a feature believed to improve patient care. This study explored barriers to adoption through several observational and survey techniques. Investigators identified ten barriers to effective use, which included workload, time to remove inapplicable reminders, the use of paper forms, accessibility of workstations, and the presence of resident physician and trainees. Discussion involves detailed account of each barrier and how certain future interventions may address them. The authors advocate using this multiprong methodology to identify barriers to effective use of new information technology.
Journal Article > Commentary
Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes.
Effken JA, Brewer BB, Patil A, Lamb GS, Verran JA, Carley K. Int J Med Inform. 2005;74:605-613.
The authors describe their experience using a computerized model to understand the impact of organizational, patient unit, and patient characteristics on safety and quality. This study was supported with a grant from the Agency for Healthcare Research and Quality (AHRQ).
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators use hospital admissions data to screen for potential quality lapses on conditions that generally don't require hospitalization if managed effectively at the primary care level.
Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.
Journal Article > Commentary
Clancy CM. Am J Med Qual. 2005;20:277-279.
Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy summarizes the Agency's research and training activities in teamwork, medical error and report analysis, multidisciplinary education, and the Patient Safety Improvement Corps.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; May 2006. AHRQ Publication No. 06-P023.
This document briefly describes a selection of AHRQ-funded patient safety research projects.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Journal Article > Study
Struggling to invent high-reliability organizations in health care settings: insights from the field.
Dixon NM, Shofer M. Health Serv Res. 2006;41(4 Pt 2):1618-1632.June 6, 2006 E-pub.
The Agency for Healthcare Research & Quality (AHRQ) conducted interviews with senior staff members at eight health systems regarding implementation of patient safety initiatives. The goal of the interviews was to identify organizational needs when implementing patient safety efforts and summarize ongoing efforts. Although all organizations had many culture-, technology-, and system-focused patient safety projects under way, most had begun only recently. All organizations reported difficulty in implementing initiatives, primarily due to lack of a mechanism for learning from other successful health care systems. AHRQ plans to develop a learning network to facilitate dissemination of effective implementation strategies among health systems.
Journal Article > Study
Mills PD, Neily J, Mims E, Burkhardt ME, Bagian J. Am J Health Syst Pharm. 2006;63:1442-1447.
This case study is part of a series that describes approaches to true management problems in health systems as a mechanism to share experiences and problem-solving strategies. The authors present the challenges that developed in the Veterans Affairs system after implementation of bar-coded medication administration (BCMA). After reviewing the background to BCMA, discussion of a collaborative breakthrough series (BTS) is explained, a model developed by the Institute for Healthcare Improvement. The case study shares the experiences of the BTS, the positive impact they had on adverse events, and lessons learned that fueled their success. A past study discussed the unintended consequences of BCMA, a past commentary shared its support for widespread implementation, and a case study described an error associated with the new technology.
Journal Article > Review
Stockwell DC, Slonim AD. J Intensive Care Med. 2006;21:199-210.
The authors provide background on patient safety in intensive care units (ICUs) and suggest practical ways to improve care in the ICU.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.