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- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 7
- Drug shortages 1
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- Interruptions and distractions 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 26
- MRI safety 1
- Nonsurgical Procedural Complications 3
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- Surgical Complications 9
- Internal Medicine 58
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- Health Care Executives and Administrators 146
Health Care Providers
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- Non-Health Care Professionals 72
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United States of America
United States Federal Government
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Search results for ""
Tufts-New England Medical Center, Tufts University School of Medicine, and Harvard University: Center for Quality Assessment & Improvement in Mental Health; 2011.
This website provides a searchable database of process measures for quality assessment and improvement in mental health and substance abuse care. It includes more than 300 measures with specifications drawn from developer source materials.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2003.
This web-accessible database provides access to evidence-based quality measures and measure sets. The mission of the National Quality Measures Clearinghouse (NQMC) is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further their dissemination, implementation, and use in order to inform health care decisions.
This website is a practical resource to review existing clinical practice guidelines in a centralized location. Key components of the site include links to full-text guidelines and an assessment function that explores the rigor and trustworthiness of each document. This website was built by the team that developed and maintained the AHRQ National Guideline Clearinghouse, which is no longer available.
Tools/Toolkit > Government Resource
Atlanta, GA: U.S. Centers for Disease Control and Prevention.
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC) strategy to promote patient safety by reducing infections in health care settings. The site includes fact sheets, a press kit, and other materials to help implement the guidelines.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Grant > Fact Sheet/FAQs
Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; March 2004. AHRQ Publication No. 04-P013.
In fiscal year 2004, the Agency for Healthcare Research and Quality (AHRQ) awarded nearly $4 million in Patient Safety Challenge Grants to support 13 new practice implementation projects. AHRQ challenged the health care community and other organizations to develop innovative solutions for the harm resulting from medical errors. The tools and procedures that emerged from these projects advanced the translation of research into clinical practice to support the agency's commitment to a medical culture grounded in safety and quality.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, and the Harvard School of Public Health; November 2004.
Five years after the Institute of Medicine's landmark report on medical errors, this survey assessed Americans' perceptions about the quality of health care, their awareness and reported usage of information in making their health care choices, and their experiences with their health care providers. A summary of the findings is provided, as well as a Webcast featuring experts discussing the survey results.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
This Web site features resources to support the Medicare Quality Improvement Program and Medicare Quality Improvement Organizations (QIOs) in delivering quality care.
Am J Nurs. March 2005;105(suppl 3):1-47.
The University of Pennsylvania School of Nursing, the Hospital of the University of Pennsylvania, the Infusion Nurses Society, and the American Journal of Nursing held an invitational symposium in Philadelphia on July 16-17, 2004. The goals of the symposium were to determine research priorities and to make clinical education and policy recommendations to ensure safe medication administration. The symposium, supported by a conference grant from the Agency for Healthcare Research and Quality (AHRQ 1 R13 HS14836-01) and by unrestricted grants from manufacturers of pharmaceuticals and other products designed to promote safe medication administration, was attended by 40 nursing and professional experts. This supplemental issue reports on the symposium proceedings.
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.
Journal Article > Study
Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; April 2005.
On April 4, 2005, AHRQ hosted "Improving Health Care for All Americans: Celebrating Success, Measuring Progress, Moving Forward." The meeting showcased successful efforts to improve health care quality and reduce racial and ethnic disparities.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Journal Article > Commentary
Hughes RG, Edgerton EA. Am J Nurs. May 2005;105:79-84.
The authors present eight practical steps for nurses to take in preventing pediatric medication errors, paying particular attention to mathematical miscalculation.
Journal Article > Study
Reichley RM, Seaton TL, Resetar E, et al. J Am Med Inform Assoc. 2005;12:383-389.
In this AHRQ-supported study, the investigators customized a commercial rule base to minimize nuisance alerts and improve alert specificity for overdosing.
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.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Rados C. FDA Consum. 2005;39:35-37.
This article reports on problems with drug names, the naming process for medications, and both industry and consumer actions that can minimize misunderstandings.
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.