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Meeting/Conference > Government Resource
This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.
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.
Tools/Toolkit > Government Resource
Washington, DC: US Department of Defense, Patient Safety Program.
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.
Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Clinician burnout is a persistent threat to patient safety, and electronic health records have been identified as a high-profile contributor to the problem. This call for public comments on a draft report seeks insights on specific goals and recommended strategies to address the issue. The approaches outlined focus on reducing the time burden associated with frontline electronic health record use. The option for submitting comments is closed.