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- Study 59
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- Special or Theme Issue 12
- Glossary 1
- Toolkit 23
- Web Resource 181
- Award 1
- Bibliography 1
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- Grant 16
- Meeting/Conference 20
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Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 42
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- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 17
- Research Directions 8
- Specialization of Care 8
- Teamwork 22
- Clinical Information Systems 27
- Transparency and Accountability 1
- Device-related Complications 10
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 27
- Fatigue and Sleep Deprivation 7
- Identification Errors 1
- Interruptions and distractions 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 34
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 10
- Second victims 1
- Surgical Complications 20
- Transfusion Complications 1
- Geriatrics 15
- Primary Care 17
- Internal Medicine 87
- Nursing 22
- Pharmacy 13
- Family Members and Caregivers 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 26
- Physicians 24
Non-Health Care Professionals
- Educators 17
- Media 1
- Patients 8
Search results for ""
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective.
Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication 01-0020.
Adverse drug events (ADEs) result in more than 770,000 annual injuries and deaths with significant resulting costs. Hospitals can reduce this burden by promoting system changes to better detect and prevent ADEs. Successful approaches are summarized.
Journal Article > Commentary
Clancy CM, Scully T. Health Aff (Millwood). 2003;22:113-115.
This commentary, written by leadership from the Agency for Healthcare and Research Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), shares the vision of how patient safety will be achieved through targeted federal initiatives. The authors discuss the shifting paradigm that must result in the way our health systems understand, learn from, and prevent errors. They discuss several strategies already in place to support the mission of their respective agencies "to support research, information, and partnerships to ensure that all Americans receive high-quality, safe, and efficient health care."
Journal Article > Study
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
Zhan C, Miller MR. JAMA. 2003;290:1868-1874.
Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.
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.
Meeting/Conference > Meeting/Conference Proceedings
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Englewood, CO: Medical Group Management Association Center for Research; 2001.
This summarizes a multidisciplinary conference (November 30 and December 1, 2000) dedicated to developing a research agenda in ambulatory patient safety. It reviews current knowledge about patient safety and contains information from presentations and discussions of conference participants. Eleven consensus recommendations are provided. The project was supported by grant number R13 HS10106 from the Agency for Healthcare Research and Quality (AHRQ).
Jt Comm J Qual Saf. 2004;30:653-680.
Special issue highlighting the winners of the 2004 John Eisenberg Award, which included Lucian Leape, MD; Peter Pronovost, MD; Robert Wachter, MD, and Kaveh Shojania, MD; Major Danny Jaghab; and the University of Pittsburgh Medical Center McKeesport, McKeesport, Pennsylvania.
Plsek P. Paper presented at: Accelerating Quality Improvement in Health Care Strategies to Speed the Diffusion of Evidence-Based Innovations; January 27-28, 2003; Washington, DC.
In discussing the complexities of health care, the author provides insights into how this complexity creates challenges to the blunt end process of medicine. This impacts health care's ability to spread and support innovation.
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.
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.
Wachter and Shojania adapted many of the cases they previously published in the academic literature, some cases previously described in the lay literature (eg, the Duke transplant mix-up and the death of Betsy Lehman at Dana-Farber Cancer Institute), and other cases never previously reported to provide a dramatic account of medical errors and the field of patient safety. Dr. Lucian Leape wrote that Internal Bleeding "shows how cognitive psychology and human factors engineering provide the way out by shifting attention from blaming individuals to fixing faulty systems." The book, now in its fourth printing, continues to be a popular choice for anyone with an interest in patient safety.
Journal Article > Study
Koppel R, Metlay JP, Cohen A, et al. JAMA. 2005;293:1197-1203.
While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors. This AHRQ-funded study identified 22 situations in which the CPOE system increased the probability of medication errors. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals' many information systems, and interface problems where the computer's requirements are different than the way clinical work is organized. The study looked at clinicians' experience in using one CPOE system at a major urban teaching hospital.
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.
Journal Article > Study
Coffey RM, Andrews RM, Moy E. Med Care. 2005;43(suppl 3):I48-I57.
The 2000 Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (AHRQ) collected patient safety indicator data from hospitals in 16 states. Data were reviewed to determine whether racial and ethnic differences in events disappear when income is introduced as a factor. The results indicate discrepancies in care for specific populations.
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.
Special or Theme Issue
Kelley E, Moy E, Dayton E, et al. Med Care. 2005;43(suppl 3):I1-I88.
Highlights from AHRQ's two inaugural reports, the 2003 National Healthcare Quality Report and the 2003 National Healthcare Disparities Report (NHDR), are provided in this special issue. A review of initial findings from these reports is included. The issue also provides articles that examine methodological challenges in developing the reports and gaps in data that were encountered in producing the first NHDR. Additional articles focus on disparities in care among children, reproductive-age women, and men and explore how the two reports can be used to improve quality and eliminate disparities.
Journal Article > Study
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1:23-32.
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. The investigators aimed to create an easy-to-use system that assists in characterizing captured incidents and allows opportunity for feedback. Discussion includes details of the design features, a table of the system-based factors contributing to reported incidents, and several screen shots of the reporting system itself. Initial data collected after implementation demonstrated wide variability in use, but consistency existed in the types of incidents reported—nearly one of every two being a near miss. The authors suggest that wide adoption of this type of reporting system, coordinated by a professional organization, may lead to data-generated improvements in care.
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.
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.
Journal Article > Commentary
Clancy CM. Jt Comm J Qual Patient Saf. 2005;31:354-356.