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- Communication Improvement 1
- Culture of Safety 2
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 1
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- Quality Improvement Strategies 1
- Teamwork 1
- Technologic Approaches 1
- Medical Complications 3
- Medication Safety 4
- Psychological and Social Complications 1
- Surgical Complications 3
Search results for "Book/Report"
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.
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.
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.
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.
Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
The primary focus on patient safety research has been in the hospital environment, but the majority of care is delivered in the ambulatory setting. This technical brief discusses the existing evidence on hospital-based safety interventions that have the potential to be implemented in ambulatory care. Strategies with moderate evidence include e-prescribing, pharmacist involvement, and hospital-to-ambulatory care transitions.
Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.
Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-P0020.
In this report, the author draws from multidisciplinary sources to share examples of practical process and design changes that can mitigate human error in health care.
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.
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.