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- Audiovisual 1
- Book/Report 8
- Legislation/Regulation 2
- Newspaper/Magazine Article 2
- Toolkit 1
- Web Resource
- Meeting/Conference 1
- Press Release/Announcement 1
- Communication Improvement 4
- Culture of Safety 5
- Education and Training 6
- Error Reporting and Analysis 4
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Logistical Approaches
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 2
- Fatigue and Sleep Deprivation 5
- Identification Errors 1
- Medical Complications 2
- Medication Safety 5
- Nonsurgical Procedural Complications 1
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- Europe 2
- North America 15
Search results for "Web Resource"
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. This report explored staffing levels in United Kingdom trusts for three tiers of expertise and found them to be inadequate across the system. The paper provides recommendations for staffing decisions for individual organizations and emphasizes the need for improved focus on care provision during routine working hours to support a healthy work force and safe patient care.
Accreditation Council for Graduate Medical Education.
Implementation of resident duty hours, meant to address fatigue in health care, has long been a subject of patient safety discussions. This website provides a summary of proposed changes to the current ACGME residency Common Program Requirements that shape working hours, offers rationale for the revisions.
Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; May 2015. DHHS NIOSH Publication No. 2015-115.
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Legislation/Regulation > Congressional Testimony
Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).
This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report.
Carayon P, Karsh B-T, Cartmill RS, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2010. AHRQ Publication No. 10-0098-EF.
The report summarizes evidence related to the impact of health information technology on workflow in outpatient settings.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.
Using data from the Healthcare Cost and Utilization Project, this report analyzed characteristics of weekend hospital stays and found that patients experienced delays in receiving care compared with patients admitted during the week.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Web Resource > Multi-use Website
National Quality Forum.
This Web site provides information on National Quality Forum activities in understanding nurses' impact on patient safety and quality.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
National Quality Forum. Washington, DC: National Quality Forum; 2009.
The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations to improve the quality and safety of patient care. The practices are organized into seven content areas: establishing leadership structures and systems, improving safety culture, honoring patient's wishes for informed consent and error disclosure, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. Since the last update in 2006, seven new practices have been added and others retired. The practices are defined so that organizations can measure the relationship between implementation of the practices and patient safety outcomes.
Meeting/Conference > Meeting/Conference Proceedings
Institute of Medicine.
This Web site provides information on a national initiative to explore and evaluate the impact of resident work hours on patient safety, resulting in the Resident Duty Hours: Enhancing Sleep, Supervision, and Safety report. Periodic open meetings were held and information from those sessions is available on the site.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Tools/Toolkit > Multi-use Website
Accreditation Council for Graduate Medical Education.
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.