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- Communication Improvement 3
- Culture of Safety 6
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- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators 10
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- Nurses 2
- Non-Health Care Professionals 4
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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.
Meeting/Conference > Government Resource
This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.
Journal Article > Commentary
Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.
Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:180-183.
The authors examine workplace factors that hinder nurses from providing safe and high-quality care.
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.
Journal Article > Study
Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.
Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.
Prior studies have documented suboptimal safety culture in long-term care facilities. This AHRQ-funded study used surveys and interviews to examine one specific aspect of safety culture—communication between nurses and physicians. Nurses noted several problems with communication, including lack of receptiveness by physicians and difficulty reaching physicians. Many nurses noted instances of unprofessional or disruptive behavior by physicians. Nurses acknowledged the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this AHRQ WebM&M commentary.
Journal Article > Commentary
The role of theory in research to develop and evaluate the implementation of patient safety practices.
Foy R, Ovretveit J, Shekelle PG, et al. BMJ Qual Saf. 2011;20:453-459.
The first decade of the patient safety movement has seen notable successes, but many highly publicized practices have been less impactful than anticipated. This AHRQ-funded expert panel calls for patient safety researchers to explicitly incorporate theories of individual behavior change and organizational improvement into the planning, implementation, and evaluation of patient safety research. Using established theoretical models has the potential to improve the odds of successful implementation of safety practices and increase the generalizability of successful strategies for other institutions. The importance of behavior change models in implementing checklists was discussed in a recent commentary, and Dr. Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change theories in an AHRQ WebM&M interview.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Journal Article > Study
Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.
Hickner J, Smith SA, Yount N, Sorra J. BMJ Qual Saf. 2016;25:588-594.
Studies of safety culture have consistently found that management has more positive perceptions of safety than frontline workers. This analysis of data from the AHRQ Medical Office Survey on Patient Safety Culture explored this finding in greater depth. The study examines the specific areas where perceptions of safety diverged between medical office management, physicians, and staff from more than 800 clinics. The investigators found that staff (including physicians and nurses) had markedly lower perceptions of the quality of staff training in patient safety and the openness of communication around safety issues compared with management. Consistent with other studies, management also had a much higher perception of overall safety than staff. As high reliability organizations rely on shared goals and open communication to ensure situational awareness, variations in perceptions of safety culture across professional roles will impair an organization's ability to address safety issues.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.