Narrow Results Clear All
- Culture of Safety 4
- Education and Training 5
- Error Reporting and Analysis 13
- Human Factors Engineering 3
- Legal and Policy Approaches 4
- Quality Improvement Strategies 6
- Research Directions 1
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Medical Complications 1
- Medication Safety 3
- Surgical Complications 2
- Europe 2
- Canada 1
- United States of America 19
Search results for "Government Resource"
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
Surgical fires can result in patient harm. This announcement provides information about causes of surgical fires and reviews FDA recommendations to prevent them, such as presurgery fire risk assessment, promoting team communication, and fire management planning. A WebM&M commentary discussed common sources of operating room fires and how to reduce risks.
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.
Soong C. National Quality Measures Clearinghouse: Expert Commentaries; June 20, 2016.
Determining the preventability of an adverse event remains a challenge. Summarizing the evidence around identifying whether a hospital readmission was avoidable and if preventable readmission rates are a reasonable measure of quality and safety, this article proposes that research focus on developing quality indicators that are more relevant to patients.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Web Resource > Government Resource
Center for Health Information and Analysis.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Audiovisual > Audiovisual Presentation
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014). (Testimony of Richard Griffin; Robert A. McDonald.)
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Web Resource > Government Resource
Nova Scotia Department of Health and Wellness.
Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to information about serious adverse events reported to the Department of Health and Wellness in Nova Scotia related to surgical procedures, product or device use, patient harm, care management, and hospital environment.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Sorra J, Famolaro T, Yount ND, Smith SA, Wilson S, Liu H. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
This annually released report of the AHRQ Hospital Survey on Patient Safety Culture comparative database presents benchmarking data for safety culture from 653 hospitals nationwide, including trending data on changes in safety culture perception over time for more than 300 hospitals. The full report contains detailed comparative data for various hospital characteristics (type and size) and respondent characteristics (work areas, staff positions, and direct patient contact). Areas of strength included teamwork, leadership, and continuous improvement, all of which have been emphasized in patient safety efforts. However, as in prior reports, concerns were voiced about the safety of handoffs. Most respondents reported that staffing was suboptimal for supporting patient safety, and a non-punitive approach to errors remains elusive for most hospitals.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
Agency information collection activities: Assessing the Impact of the National Implementation of TeamSTEPPS Master Training Program; comment request.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. August 27, 2013;78:52927-52929.
This notice requests comments on a proposed project to evaluate TeamSTEPPS training and implementation efforts. The comment submission process is now closed.
National Advisory Group on the Safety of Patients in England. London, England: Crown Publishing; August 2013.
Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.
Keogh B. London, UK: National Health Service; July 2013.
Outlining findings from an investigation into care delivered at National Health Service trusts with high mortality rates, this report details weaknesses in the organizations and recommends actions to address them.
Web Resource > Government Resource
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.
Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND Corporation; 2009. ISBN: 9780833047748.
This publication reports the results of a 2-year examination to determine the effectiveness of US efforts to improve patient safety, explore hospitals' experience with the AHRQ patient safety culture survey, and highlight trends in patient safety improvement.
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Pediatric Quality Indicators focus on quality of care inside hospitals and identify potentially avoidable hospitalizations among children.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.