Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 4
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 12
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Medication Errors/Preventable Adverse Drug Events 7
- MRI safety 1
- Surgical Complications 1
- Health Care Executives and Administrators 12
Health Care Providers
- Physicians 13
- Non-Health Care Professionals 3
- Patients 1
- North America 18
Search results for "Government Resource"
- Government Resource
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.
Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; May 2015. DHHS NIOSH Publication No. 2015-115.
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
This handbook prepared by the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation provides a comprehensive summary of important patient safety and quality improvement concepts for frontline nurses. Experts in each topic area reviewed the latest published evidence to assemble sections on providing patient-centered care, nurses' working conditions and work environment, critical opportunities for improving quality and safety, and practical tools for implementing patient safety interventions for practicing nurses.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
Health IT implementation stories: HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study.
AHRQ National Resource Center for Health Information Technology.
This article describes an AHRQ-funded project to discern whether a standardized, computerized tool can improve handoff communication.
Food and Drug Administration (FDA) Patient Safety News. Show #60. February 2007.
This video segment shares recommendations for providers about safe prescribing of methadone for pain control, including heightened patient monitoring and encouraging patients to ask questions about how the drug will affect them.
Meeting/Conference > Government Resource
Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.
US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.
The US Food and Drug Administration invited experts to comment on how labels for intravenous drugs could be designed to ensure the safe use of these medications through informed label redesign efforts.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.
The Centers for Disease Control and Prevention (CDC) investigated adverse events related to cough and cold medications in infants. The investigation found three instances in which these medications were considered the underlying cause of death.
Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.
This video story reviews a high-profile medication error and suggests actions to prevent similar incidents from occurring.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-544.
This investigation determined that the U.S. Veterans Administration has taken steps to improve the reliability of their practitioner licensure and certification screening processes for employees and new hires but found that some weaknesses still exist.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.
This alert reports five instances of accidental infusion into an IV or peripherally inserted central catheter (PICC) line and suggests actions for preventing similar errors.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 27, 2005.
This announcement alerts patients and practitioners to a problem with glucose meters made by Abbott Diabetes Care. The meters have a measurement setting that, if inadvertently switched, could cause an inaccurate reading.
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.
Tools/Toolkit > Fact Sheet/FAQs
National Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. AHRQ Publication No. 04-P025.
This fact sheet presents 30 safe practices that can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all applicable health care settings to reduce the risk of harm to patients. The practices are derived from a 2003 consensus report developed by the National Quality Forum.
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.