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Search results for ""
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective.
Tools/Toolkit > Measurement Tool/Indicator
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; September 2005.
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 Inpatient Quality Indicators include inpatient mortality for certain procedures and medical conditions; utilization of procedures for which there are questions of underuse, overuse, and misuse; and volume of procedures for which evidence suggests that a higher volume is associated with lower mortality.
Meeting/Conference > Meeting/Conference Proceedings
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).
Web Resource > Multi-use Website
Human Factors Engineering Team, Center for Devices and Radiological Health, Office of Communication, Education, and Radiation Programs (OCER), Division of Device User Programs and Systems Analysis (DDUPSA), 1350 Piccard Drive, HFZ-230, Rockville, MD 20850.
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with use error. The U.S. Food and Drug Administration (FDA) works with manufacturers to ensure the application of HFE in the design of new products. In addition to providing information on these design issues, this site facilitates the reporting of unsafe incidents with medical devices.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Journal Article > Review
Zhan C, Kelley E, Yang HP, et al. Med Care. Mar 2005;43(suppl 3):I42-I47.
Each year, the Agency for Healthcare Research and Quality (AHRQ) reports on health care quality through the National Healthcare Quality Report (NHQR); a chapter of the report focuses on patient safety. This study reviews the challenges in assessing and reporting on national patient safety performance for the first NHQR and discusses developments that will help improve assessment in the future.
Journal Article > Study
Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.
Journal Article > Study
Coffey RM, Andrews RM, Moy E. Med Care. 2005;43(suppl 3):I48-I57.
The 2000 Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (AHRQ) collected patient safety indicator data from hospitals in 16 states. Data were reviewed to determine whether racial and ethnic differences in events disappear when income is introduced as a factor. The results indicate discrepancies in care for specific populations.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; April 2005.
On April 4, 2005, AHRQ hosted "Improving Health Care for All Americans: Celebrating Success, Measuring Progress, Moving Forward." The meeting showcased successful efforts to improve health care quality and reduce racial and ethnic disparities.
Special or Theme Issue
Kelley E, Moy E, Dayton E, et al. Med Care. 2005;43(suppl 3):I1-I88.
Highlights from AHRQ's two inaugural reports, the 2003 National Healthcare Quality Report and the 2003 National Healthcare Disparities Report (NHDR), are provided in this special issue. A review of initial findings from these reports is included. The issue also provides articles that examine methodological challenges in developing the reports and gaps in data that were encountered in producing the first NHDR. Additional articles focus on disparities in care among children, reproductive-age women, and men and explore how the two reports can be used to improve quality and eliminate disparities.
Journal Article > Government Resource
Assessing the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites, United States, January 1–June 15, 2004.
Centers for Disease and Control Prevention. MMWR Morb Mortal Wkly Rep. 2005;54:380-383.
The Centers for Disease Control (CDC), the Consumer Product Safety Commission (CPSC), and the Food and Drug Administration (FDA) collaboratively created this surveillance project to estimate incidence of adverse drug events. The summary describes the evaluation of the system, based on studying reports from a convenience sample of participating hospitals. While the sensitivity of capturing events was low, the positive predictive value that reported events represented in actual cases was high. An editorial note suggests that this reporting system may represent an important, ongoing resource for recording and preventing future adverse drug events.
Journal Article > Study
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1:23-32.
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. The investigators aimed to create an easy-to-use system that assists in characterizing captured incidents and allows opportunity for feedback. Discussion includes details of the design features, a table of the system-based factors contributing to reported incidents, and several screen shots of the reporting system itself. Initial data collected after implementation demonstrated wide variability in use, but consistency existed in the types of incidents reported—nearly one of every two being a near miss. The authors suggest that wide adoption of this type of reporting system, coordinated by a professional organization, may lead to data-generated improvements in care.
Journal Article > Study
Hurley JS, Roberts M, Solberg LI, et al. J Gen Intern Med. 2005;20:331-333.
This AHRQ–funded study retrospectively examined the failure rate of recommended laboratory surveillance for patients on specific chronic medications. Using claims data from two large health plans, the investigators selected 11 drugs and their recommended lab testing intervals to capture and analyze data. Results suggested that nearly half of those requiring a chronic medication were subject to a potential laboratory monitoring error per year. Discussion includes detailed presentation of the potential error rates and how they differed among specific drugs and lab tests. The authors conclude that the prevalence of inadequate laboratory monitoring should stimulate further research about its impact on several clinical outcomes.
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.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.
Web Resource > Government Resource
US Food and Drug Administration.
MedWatch, the Food and Drug Administration (FDA) Safety Information and Adverse Event Reporting Program, serves both health care professionals and consumers of health care products. The site shares safety information about medications and medical products that are regulated by the FDA.
Journal Article > Study
Encinosa WE, Bernard DM. Inquiry. 2005;42:60–72.
This AHRQ–funded study examined the relationship between hospital profit margins and the rate of patient safety events. Using data from 176 acute care hospitals in Florida, investigators categorized hospitals into four tiers based on their reported profit margins and compared event rates from more than one million surgical hospitalizations. Findings illustrated an inverse relationship, with the highest event rate occurring in hospitals with the lowest margins. The authors suggest that growing financial constraints may limit a hospital's investment in patient safety, leading to greater numbers of adverse events.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Audiovisual > Meeting/Conference Proceedings
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.