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- Communication Improvement 2
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 2
- Technologic Approaches 2
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Audiovisual > Meeting/Conference Proceedings
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.
Shekelle PG, Morton SC, Keeler EB. Evidence Report/Technology Assessment No. 132 (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003.) Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006.
The authors reviewed the literature on health information technology (HIT). They conclude that HIT may reduce pediatric medication errors, have the potential to improve safety and quality, and require more study to fully articulate the cost and implementation issues.
Journal Article > Study
Kaushal R, Goldmann DA, Keohane CA, et al. Ambul Pediatr. 2007;7:383-389.
The incidence of adverse drug events (ADEs) among children has been well characterized in hospital inpatients, but less studied in the outpatient setting. Conducted at six pediatric outpatient practices, this AHRQ-funded prospective cohort study evaluated the frequency of medication errors via chart review, review of prescriptions, and patient surveys. The overall rate of preventable ADEs was similar to a prior outpatient study, but nearly three-quarters of events were attributable to errors in administering drugs by the parents. Parents also did not consistently inform clinicians of ameliorable ADEs when they occurred, leading the authors to conclude that communication between clinicians and parents around the issue of medication side effects must be improved.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.
For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.