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- Communication Improvement 1
- Culture of Safety 8
- Education and Training 3
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
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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 > Study
Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.
Rochon PA, Field TS, Bates DW, et al. J Am Geriatr Soc. 2005;53:1780-1789.
The investigators in this AHRQ-funded project offer insights from their experience in implementing computerized provider order entry (CPOE) in a geriatric care setting.
Journal Article > Study
A comparison of two distribution methods on response rates to a patient safety questionnaire in nursing homes.
Lapane KL, Quilliam BJ, Hughes CM. J Am Med Dir Assoc. 2007;8:446-452.
This AHRQ-funded study found that nursing home employees were more likely to have a positive opinion of the workplace culture of safety when the survey was distributed on site rather than mailed.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing and a tendency to blame individuals for problems. This website hosts the AHRQ survey for nursing homes along with additional materials to assist organizations in using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient safety in a nursing home and report the results. The resource provides guidance on topics such as data collection, data organization, survey forms, and nursing home staff selection.
Journal Article > Study
Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.
Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.
Prior studies have documented suboptimal safety culture in long-term care facilities. This AHRQ-funded study used surveys and interviews to examine one specific aspect of safety culture—communication between nurses and physicians. Nurses noted several problems with communication, including lack of receptiveness by physicians and difficulty reaching physicians. Many nurses noted instances of unprofessional or disruptive behavior by physicians. Nurses acknowledged the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this AHRQ WebM&M commentary.
Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0001.
This set of training materials provides techniques to help improve staff monitoring of nursing home residents' conditions to prevent delays and minimize harm.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0071.
Developed by the Agency for Healthcare Research and Quality (AHRQ), the Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. The survey expanded on the original hospital-based survey. Similar to that tool, AHRQ now provides annual comparative reports that present benchmarking data for safety culture across different regions, facility types, and staff positions. This edition shares data from 226 nursing homes and more than 16,000 staff. Notable findings include widespread concern about punitive responses to mistakes and safety concerns about poor staffing. An AHRQ WebM&M commentary discussed quality and safety issues in the nursing home setting.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Grant > Government Resource
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services. August 25, 2015. Program Announcement No. PA-15-339.
Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-EHC022-EF.
Efforts to maintain patient autonomy can detract from ensuring residents' safety in nursing homes. Common safety issues in nursing homes are medication errors, falls, and inappropriate use of restraints. This technical brief discusses gaps in the research base that hinder understanding of the safety hazards in the residential care environment.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in the nursing home setting. The 2016 user comparative database report summarizes survey data obtained from 12,395 staff and provider respondents working in 209 nursing homes. The report highlights two areas of safety culture in which nursing homes appear to do well: overall perceptions of resident safety and feedback and communication about incidents. Areas identified as needing improvement across most nursing homes included staffing issues and ensuring a nonpunitive response to mistakes. A previous PSNet perspective provided insights on safety culture.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.