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- Study 3
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- Culture of Safety 35
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Error Reporting and Analysis
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Quality Improvement Strategies
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- Drug shortages 1
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- Medical Complications 32
- Medication Errors/Preventable Adverse Drug Events 17
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 125
- United States Federal Government 136
Search results for "Government Resource"
- Government Resource
- Quality Improvement Strategies
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.
Veazie S, Peterson K, Bourne D. Washington, DC: Department of Veterans Affairs; May 2019.
This brief evaluated published accounts of frameworks for implementing high reliability organizations to examine which approaches have been most successful. The analysis identified five common implementation strategies: leadership development, data system utilization, quality improvement interventions, training and learning, and safety culture.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
Tools/Toolkit > Fact Sheet/FAQs
Gray D, Azam I. Rockville, MD: Agency for Healthcare Research and Quality; October 2018. AHRQ Publication No. 18(19)-0033-4-EF.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements in areas of focus such as hospital-acquired infections. The most recent update documented more than two-thirds improvement in patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
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.
Web Resource > Government Resource
2nd Floor, 151 Buckingham Palace Road, London, SW1W 9SZ.
The National Health Service (NHS) is a global leader in patient safety improvement. This website coalesces information and activities generated by three NHS improvement efforts: patient compensation, performance assessment, and fair resolution of appeals between the NHS and primary care contractors.
Tools/Toolkit > Government Resource
Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement.
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
This toolkit provides resources to help augment testing processes in ambulatory care settings, including tools for identifying areas of concern and measuring improvements.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Web Resource > Course Material/Curriculum
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
Both organizational culture and the physical environment affect the safety of care delivery. This toolkit provides resources to help organizations assess hazards related to the design of their facilities. The toolkit focuses on six areas of safety: infections, falls, medication errors, security, injuries of behavioral health, and patient handling.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.
Wright J, Lawton R, O'Hara J, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.
Grant > Fact Sheet/FAQs
Partnership for Patients and the Hospital Improvement Innovation Networks: Continuing Forward Momentum on Reducing Patient Harm.
Fact Sheets. Baltimore, MD: Centers for Medicare & Medicaid Services; September 29, 2016.
The Partnership for Patients program is credited with supporting harm reduction in hospitalized patients across the United States through the Hospital Engagement Networks (HEN). This fact sheet summarizes the next round of funding that will build on HEN accomplishments to support innovation with a goal of reducing hospital-acquired conditions and preventable readmissions by 2019.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.
This funding program will support research demonstration projects that explore systemic strategies to enhance medication safety. The submission process for the program is now closed.
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Journal Article > Government Resource
Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.
Novosad SA, Sapiano MR, Grigg C, et al. MMWR Morb Mortal Wkly Rep. 2016;65:864-869.
Sepsis has been a significant focus of quality improvement initiatives. In this retrospective review, researchers sought to identify patient characteristics, risk factors, and infections that might inform sepsis diagnosis, treatment, and prevention efforts. The medical records of a random sample of 246 adult and 79 pediatric patients with codes for severe sepsis or septic shock across 4 New York hospitals were reviewed. Investigators found that 72% of patients had exposure to at least one health care factor during the 30 days prior to being admitted for sepsis or a medical condition requiring frequent health care contact. Pneumonia was the most frequently documented infection causing sepsis. They concluded that reducing sepsis will require an ongoing focus on infection prevention.