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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.
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.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Journal Article > Study
Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.
Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.
This AHRQ-funded multicenter prospective study used data from a previously described voluntary reporting system, the Intensive Care Unit Safety Reporting System (ICUSRS), to compare the types and severity of safety problems for medical and surgical ICU patients. Despite differences in the types of patients, the types of errors reported were generally similar between the two groups, with most errors being attributable to training and team system factors (such as communication). Prior studies using data from the ICUSRS have analyzed factors contributing to medication order entry errors and procedural errors.
Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III.
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2007. ISBN: 9780833042170
This annual report discusses AHRQ's involvement in patient safety activities between 2004-2005 and provides suggestions for future actions. This document is the third of four yearly reports funded by AHRQ to assess their work.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 23, 2010.
This issue features successful patient safety innovations pertaining to disclosure, multidisciplinary patient safety conferences, and proactive reporting.
Web Resource > Government Resource
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.