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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.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
Telehealth is a rapidly expanding approach of adopting technology to deliver health care services and information that improves the quality, safety, access, efficiency, and costs of care. Although the evidence that telehealth achieves these aims is still lacking, this report outlines AHRQ's health information technology portfolio, which funded a number of programs to evaluate this promising technology and approach. The report findings are based on interviews with lead investigators. It discusses the scope of the projects funded, the technical challenges faced, the organizational and cultural issues encountered, and the opportunities ahead.
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.
Rockville, MD: Agency for Healthcare Research and Quality. June 3, 2009.
This podcast discusses an AHRQ project to design information technology systems that support safe care transitions for elderly patients.
Journal Article > Study
Linzer M, Manwell LB, Williams ES, et al; MEMO Investigators. Ann Intern Med. 2009;151:28-36.
The quality and safety of care in the ambulatory setting may require a different framework for assessment and improvement from that often applied in the hospital setting. The relationships between work environments and the care delivered in those environments similarly may differ between care settings. This AHRQ-funded study found that more than half of surveyed physicians reported time pressures during office visits and low control over their work, though only a quarter reported burnout. While adverse workflow and poor organizational culture were associated with adverse physician reactions (e.g., low satisfaction, stress, and burnout), there were no associations between these reactions and care quality or errors. This study builds on past analyses of these relationships from the same investigative team.
Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.
Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.
Falls are a major source of preventable morbidity and mortality for elderly patients in both the ambulatory care and hospital setting. However, efforts to prevent falls have been limited by a lack of high quality evidence supporting specific prevention strategies. This AHRQ-funded systematic review identified several focused interventions, including physical therapy, exercise, and vitamin D supplementation, that appeared to reduce the risk of falls in outpatients. The evidence base in this area has also been strengthened by recent studies showing that patient education and individualized interventions can prevent falls in hospitalized patients.
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
Tools/Toolkit > Government Resource
Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.
Sorra J, Famolaro T, Dyer N, Smith S, Liu H, Ragan M. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0052.
The Agency for Healthcare Research and Quality's (AHRQ) Medical Office Survey on Patient Safety Culture is designed to assess safety culture in outpatient clinics. This inaugural database describes survey results from more than 23,000 respondents (including both clinical and administrative staff) from 934 participating offices. Notable results include generally positive perceptions of teamwork and patient tracking, but the majority of respondents felt that production pressures adversely affected safety. The database is freely available from AHRQ for benchmarking and comparison purposes, as is the Hospital Survey on Patient Safety Culture database.
Web Resource > Multi-use Website
Massachusetts Department of Public Health.
The majority of early patient safety interventions focused on the hospital setting, but there is a growing determination to improve safety practices across the ambulatory sphere as well. This AHRQ-funded project, Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction (PROMISES), created a collaborative learning network of Massachusetts primary care practices and patient safety leaders. Program coaches visited 16 pilot primary care offices and worked directly with improvement teams to implement safe practices. The project also includes a report from physicians, malpractice insurers, and policy experts translating the hospital-based consensus statement, "When Things Go Wrong," into clear recommendations for ambulatory adverse events. The Web site provides various materials, including recorded lectures, case study videos, and tools to assist individuals and teams with enhancing outpatient safety. A past AHRQ WebM&M perspective explored patient safety in the office setting.
Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.
For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.