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Education and Training
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Error Reporting and Analysis
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Legal and Policy Approaches
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Quality Improvement Strategies
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- Drug shortages 7
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- Inpatient suicide 1
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Non-Health Care Professionals
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 405
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Search results for "Government Resource"
- Government Resource
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
Web Resource > Government Resource
Doctors' Association UK.
This website provides information about a National Health Service (NHS) campaign to shift response to errors from blame to an approach that embraces fairness, openness, learning, and patient and health care professional well-being. The initiative offers materials and community opportunities to engage NHS physicians in the work required to establish just culture throughout the system.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality.
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. This website provides data submitted from PSOs and other organizations in reports, chartbooks, and dashboards. These tools enable the wide dissemination of information to inform organizational improvement strategies.
NHS Improvement. July 2, 2019.
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.
National Quality Forum.
Patient safety organizations collect data across various systems and states. This announcement calls for review of the current beta version of the common formats developed to provide a standardized method to collect and report incident data to patient safety organizations. The current comment period is of open duration.
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Veazie S, Peterson K, Bourne D. Washington, DC: Department of Veterans Affairs; May 2019.
This brief evaluated published accounts of frameworks for implementing high reliability organizations to examine which approaches have been most successful. The analysis identified five common implementation strategies: leadership development, data system utilization, quality improvement interventions, training and learning, and safety culture.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
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.
Grant > Government Resource
US Department of Health and Human Services. Program Announcement No. RFA-HS-19-003.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
Gaps in responding to concerns about clinician competence can result in care failures. This report examined Veterans Health Administration (VHA) actions associated with National Practitioner Data Bank records and found variation in how organizations responded to that information including some instances where VHA facilities inappropriately hired providers. The Government Accountability Office makes seven recommendations to address this problem.
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.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
The introduction of information technology has transformed health care. This notice of intent from AHRQ announces an upcoming funding opportunity to support research exploring the adoption of interoperable information technologies to improve communication during transitions. The pending funding will help to refine and develop methods to assess implementation success.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Journal Article > Government Resource
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Clinician burnout is a persistent threat to patient safety, and electronic health records have been identified as a high-profile contributor to the problem. This call for public comments on a draft report seeks insights on specific goals and recommended strategies to address the issue. The approaches outlined focus on reducing the time burden associated with frontline electronic health record use. The option for submitting comments is closed.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
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.
Tools/Toolkit > Fact Sheet/FAQs
Gray D, Azam I. Rockville, MD: Agency for Healthcare Research and Quality; October 2018. AHRQ Publication No. 18(19)-0033-4-EF.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements in areas of focus such as hospital-acquired infections. The most recent update documented more than two-thirds improvement in patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
Tools/Toolkit > Fact Sheet/FAQs
London, England: NHS Resolution; 2018.
Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers information to help clinicians understand the value of effective apologies along with tips for organizations to support open disclosure efforts.
Web Resource > Government Resource
QualityNet. Centers for Medicare and Medicaid Services.
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Audiovisual > Audiovisual Presentation
Agency for Healthcare Research and Quality. July 25, 2018.
Tracking the intersection of organizational culture with health information technology use can inform patient safety improvement efforts. This webinar introduced supplemental items to the AHRQ Hospital Survey on Patient Safety Culture and discussed the results of a pilot project integrating the items into assessment efforts. Featured speakers included Dr. Jeff Brady and Dr. Tejal Gandhi.
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
Both organizational and individual accountability are required to ensure safe care. This analysis of Department of Veterans Affairs (VA) responses to whistle-blower concerns and reports of staff misconduct found that the VA has procedures for investigating these allegations but determined that the process was unreliable. The report outlines recommendations for improvement including ensuring whistle-blowers are treated fairly and assigning responsibilities across the hierarchy to ensure incidents receive the appropriate attention.
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.
Hoffman RM, Mirarchi FL. PA-PSRS Patient Saf Advis. June 2018;15.
Patient harm associated with advance directive interpretation errors is rare, but these mistakes can have negative psychological consequences for care teams, patients, and families. Discussing research exploring factors that contribute to these misunderstandings, this article recommends actions to help patients articulate end-of-life care preferences and ensure those instructions are accurately shared with their families and the clinical teams acting on their behalf.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
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.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
Surgical fires can result in patient harm. This announcement provides information about causes of surgical fires and reviews FDA recommendations to prevent them, such as presurgery fire risk assessment, promoting team communication, and fire management planning. A WebM&M commentary discussed common sources of operating room fires and how to reduce risks.
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
Tools/Toolkit > Government Resource
National Health Service.
Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Drug Enforcement Administration. April 28, 2018.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
Adverse event reporting is an important step toward failure reduction. However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their impact on safety. This publication analyzed reporting activity and action in the Defense Health Agency. The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying reporting requirements.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
Silver Spring, MD: US Food and Drug Administration; April 2018.
Reliable use of medical devices is an important contributor to safe health care delivery. This report describes the US Food and Drug Administration's plan to raise awareness of problems with devices in the field, develop new devices with better safety and cybersecurity protections, and enhance innovation and the product life cycle through regulation.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
Research on patient safety improvements has largely focused on the acute care environment. This grant will support funding for demonstration and implementation projects aimed at identifying and evaluating the application of evidence-based practices in ambulatory care and long-term care to improve patient safety. The deadline for submitting applications is September 8, 2021.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; March 2018.
Organizational culture can affect the use of tools and processes implemented to improve safety. This release of supplemental items to be used in conjunction with the AHRQ Hospital Survey on Patient Safety Culture can help organizations explore how culture affects the use of health information technology. Included with the data set is a report of initial results regarding its use in the field.