Narrow Results Clear All
- Commentary 183
- Review 53
- Study 622
- Slideset 1
- Book/Report 114
- Legislation/Regulation 13
- Newspaper/Magazine Article 191
- Special or Theme Issue 12
- Toolkit 19
- Web Resource 104
- Award 9
- Clinical Guideline 1
- Grant 2
- Meeting/Conference 10
- Press Release/Announcement 9
Communication between Providers
- Sbar 10
- Communication between Providers 234
Culture of Safety
- Just Culture 12
Education and Training
- Simulators 12
- Students 9
Error Reporting and Analysis
- Error Analysis 102
- Never Events 26
Human Factors Engineering
- Checklists 22
Legal and Policy Approaches
- Regulation 25
- Logistical Approaches 115
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 46
- Reminders 12
- Research Directions 2
Specialization of Care
- Hospitalists 17
- Teamwork 76
- Clinical Information Systems 152
- Transparency and Accountability 8
- Alert fatigue 3
- Device-related Complications 50
- Diagnostic Errors 32
- Discontinuities, Gaps, and Hand-Off Problems 200
- Drug shortages 4
- Failure to rescue 5
- Fatigue and Sleep Deprivation 41
- Identification Errors 16
- Inpatient suicide 4
- Interruptions and distractions 11
- Delirium 3
- Medication Errors/Preventable Adverse Drug Events 189
- MRI safety 1
- Nonsurgical Procedural Complications 12
- Overtreatment 1
- Psychological and Social Complications 50
- Second victims 6
- Surgical Complications 61
- Transfusion Complications 6
- Ambulatory Care 144
- General Hospitals 152
- Long-Term Care 8
- Outpatient Surgery 4
- Patient Transport 2
- Psychiatric Facilities 3
- Allied Health Services 1
- Family Medicine 160
- Hospital Medicine 1120
- Cardiology 11
- Geriatrics 31
- Primary Care 160
- Nursing 54
- Palliative Care 1
- Pharmacy 118
- Family Members and Caregivers 15
- Health Care Executives and Administrators 1018
Health Care Providers
- Nurses 67
- Pharmacists 41
- Physicians 154
Non-Health Care Professionals
- Educators 99
- Engineers 32
- Media 7
- Policy Makers 134
- Patients 126
- Australia and New Zealand 1
- Europe 6
- Canada 4
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 87
- United States Federal Government 134
Search results for "United States of America"
- General Internal Medicine
- United States of America
Meeting/Conference > Maryland Meeting/Conference
Armstrong Institute for Patient Safety and Quality. October 8, 2019; Constellation Energy Building Conference Center, Baltimore, MD.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. This conference will cover how to utilize CUSP, including understanding and addressing challenges to implementation.
Meeting/Conference > United States Meeting/Conference
AHA Team Training. June 27–November 5, 2019.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
Audiovisual > Audiovisual Presentation
Rockville, MD: Agency for Healthcare Research and Quality; July 2016.
This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-9 to ICD-10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.
Tools/Toolkit > Fact Sheet/FAQs
Chicago, IL: American Society for Healthcare Risk Management; 2015.
This fact sheet lists 10 patient safety concerns such as adverse drug events and offers tips to address them.
Journal Article > Study
Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.
Zaheer S, Ginsburg L, Chuang YT, Grace SL. Health Care Manage Rev. 2015;40:13-23.
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
This radio news segment reports on patient falls, including risk factors and prevention strategies.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Tools/Toolkit > Multi-use Website
Hospital Engagement Network 2.0. Chicago, IL: Health Research & Educational Trust and American Hospital Association; 2017.
Journal Article > Commentary
Halpern SD, Detsky AS. N Engl J Med. 2014;370:1086-1089.
Tracking changes in resident physician training since the landmark Libby Zion case in 1984, Drs. Halpern and Detsky review both the intended and unintended effects of ACGME work hour and supervision regulations. They describe the incremental loss of the traditional model of graded autonomy for residents and point out the lack of evidence in support of this new approach. For instance, a recent study showed that having in-house critical care attendings overnight did not improve outcomes compared with having in-house residents with as-needed telephone access to their supervisors. The authors call for the ACGME and other training program regulators to promote evaluations of various models of graded autonomy, rather than set "one rigid standard on the basis of conjecture alone." Studies should examine outcomes of future patients cared for by physicians that were exposed to different training environments, as well as shorter-term evaluations of residents' current clinical competence. A prior AHRQ WebM&M interview with Dr. Thomas Nasca, head of the ACGME, discussed duty hours and the balance of autonomy with oversight.
Journal Article > Study
Paciotti B, Roberts KE, Tibbetts KM, et al. Jt Comm J Qual Patient Saf. 2014;40:187-192.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
Reese SM. Information Week. March 11, 2014.
This article describes how wearable technologies for clinicians can improve workload distribution, information gathering, and staffing decisions to address safety issues, particularly nurse fatigue.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Journal Article > Study
National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations.
Geller AI, Shehab N, Lovegrove MC, et al. JAMA Intern Med. 2014;174:678-686.
According to this large study, nearly 100,000 emergency department visits and 30,000 hospitalizations in the United States each year are due to insulin-related hypoglycemia and errors. Patients older than 80 years were found to be at highest risk for these adverse events.
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.
This investigation found that although use of electronic health records (EHRs) in Medicare and Medicaid programs increased between 2011 and 2012, EHR systems lack the ability to track quality and safety to measure improvements. The report recommends developing a comprehensive strategy to compile clinical quality measurement data.
Web Resource > Multi-use Website
Beth Israel Deaconess Medical Center and Massachusetts Medical Society.
Journal Article > Government Resource
Fridkin S, Baggs J, Fagan R, et al; National Center for Emerging and Zoonotic Infectious Diseases, CDC. MMWR Morb Mortal Wkly Rep. 2014;63:194-200.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Journal Article > Commentary
Chopra V, McMahon LF Jr. JAMA. 2014;311:1199-1200.
Journal Article > Study
"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.
Singh R, Hickner J, Mold J, Singh G. J Patient Saf. 2014;10:20-28.
Unreliable test result management systems and failure to follow-up on abnormal test results are common issues in ambulatory care. Using a modified failure mode and effect analysis methodology, this study sought to prospectively identify safety hazards in the laboratory testing process in primary care clinics.