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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 2
- Medical Complications 3
- Medication Safety 4
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- Intensive Care Units
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Tools/Toolkit > Multi-use Website
Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
Infants discharged from the neonatal intensive care unit to home are particularly vulnerable to care coordination errors. This four-component toolkit includes materials to help hospitals implement a coach program to educate providers and families about common communication and health concerns that arise during this transition.
MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.
This announcement reports on numerous errors in which an oral medication, nimodipine, was administered intravenously and describes how such errors occur.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs.
Rockville, MD: Agency for Healthcare Research and Quality; February 19, 2009.
This announcement highlights a program in 10 states that will test methods of reducing central-line–associated blood stream infections in hospital intensive care units.
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.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2005. AHRQ Publication No. 05-P003-3.
This program brief summarizes patient safety research projects funded by the Agency for Healthcare Research and Quality (AHRQ) since 2001.