Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 14
- Education and Training 11
Error Reporting and Analysis
- Error Reporting 29
- Human Factors Engineering 4
- Legal and Policy Approaches 18
- Logistical Approaches 3
- Policies and Operations 3
- Quality Improvement Strategies 30
- Research Directions 2
- Specialization of Care 1
- Teamwork 3
- Clinical Information Systems 12
- Transparency and Accountability 4
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 4
- Inpatient suicide 1
- Medical Complications 18
- Medication Errors/Preventable Adverse Drug Events 14
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 2
- Surgical Complications 12
- Internal Medicine 38
- Surgery 9
- Nursing 2
- Pharmacy 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators 96
Health Care Providers
- Nurses 3
Non-Health Care Professionals
- Media 2
- Patients 5
- Canada 3
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 70
- United States Federal Government 96
Search results for "Government Resource"
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
Both organizational and individual accountability are required to ensure safe care. This analysis of Department of Veterans Affairs (VA) responses to whistle-blower concerns and reports of staff misconduct found that the VA has procedures for investigating these allegations but determined that the process was unreliable. The report outlines recommendations for improvement including ensuring whistle-blowers are treated fairly and assigning responsibilities across the hierarchy to ensure incidents receive the appropriate attention.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
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.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July 2017. Report No. OEI-02-17-00250.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.
Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.