Search results for "Active Errors"

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, and teaching materials, and it has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

Standardization has been embraced as a strategy to improve health literacy and to reduce patient misunderstanding of medication instructions. This tool provides standard language that clarifies directions for patients regarding when they should take their medications.

This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.

Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.

This survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies. The data collection process for the latest national comparison is now closed.

This Web site provides information about a national program focused on improving safety in ambulatory surgery. The initiative includes surgical safety checklists, webinars, and other tools, with the goal of enhancing safety culture and reducing surgical site infections.

This resource offers a collection of tools and initiatives to help organizations address the pervasive issue of chronic opioid misuse. Interventions include implementation of a protocol and education about overdose prevention.

This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.

This notice calls for comments on a proposed government plan to research and promote adverse drug event reduction. The process for submitting public comments is now closed.

This report highlights findings from 24 AHRQ-funded projects investigating how health information technology can improve clinician decision making, care coordination, and clinical workflow to achieve better outcomes.

This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.

Conducted as part of the AHRQ Making Health Care Safer II report, this article reviews the expanding research base in diagnostic error prevention. Several promising systems-based interventions were identified that seemed to reduce diagnostic errors, although the strength of evidence for these strategies was low.

This announcement highlights projects funded by the Agency for Healthcare Research and Quality to reduce incidence of health care–associated infections.

This Agency for Healthcare Research and Quality (AHRQ)–supported study prospectively observed intensive care units over a 1-year period and analyzed captured incidents. Investigators used a variety of methods, including direct observation, to examine nearly 1500 patient-days. The incident rate per 1000 patient-days was greatest for the category defined as serious errors followed by that of preventable adverse events. Discussion provides details of the clinical patient characteristics, the range in severity of incidents, and specific examples and frequencies of the defined event types. The authors conclude that, while critical care settings offer vital services in treating patients, the setting also carries noted risks for adverse events and errors, and it is important to promote ongoing improvement efforts.

The authors of this AHRQ-funded study applied techniques from human factors engineering and observational research to analyze interruptions in the cognitive work of nurses. They found that most interruptions took place during the medication preparation process.

The authors present eight practical steps for nurses to take in preventing pediatric medication errors, paying particular attention to mathematical miscalculation.