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- Commentary 55
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Education and Training
- Simulators 10
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Error Reporting and Analysis
- Never Events 12
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Legal and Policy Approaches
- Regulation 19
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- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 22
- Research Directions 9
- Specialization of Care 13
- Teamwork 30
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- Transparency and Accountability 1
- Device-related Complications 50
- Diagnostic Errors 21
- Discontinuities, Gaps, and Hand-Off Problems 46
- Drug shortages 4
- Fatigue and Sleep Deprivation 10
- Identification Errors 4
- Interruptions and distractions 4
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 122
- MRI safety 2
- Nonsurgical Procedural Complications 10
- Overtreatment 2
- Psychological and Social Complications 12
- Second victims 1
- Surgical Complications 40
- Transfusion Complications 3
- Allied Health Services 1
- Geriatrics 26
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- Internal Medicine 172
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- Health Care Executives and Administrators 460
Health Care Providers
- Nurses 49
- Pharmacists 37
- Physicians 68
Non-Health Care Professionals
- Educators 31
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- Media 1
- Patients 96
- Europe 1
United States of America
United States Federal Government
- Department of Health and Human Services (HHS)
- United States Federal Government
- United States of America
Search results for "Department of Health and Human Services (HHS)"
- Department of Health and Human Services (HHS)
Meeting/Conference > United States Meeting/Conference
AHA Team Training. April 1–November 5, 2019.
Meeting/Conference > Maryland Meeting/Conference
Johns Hopkins Armstrong Institute for Patient Safety and Quality. March 5-6, 2019; Constellation Energy Building, Baltimore, MD.
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.
Journal Article > Study
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019 Jan 10; [Epub ahead of print].
Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.
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 deadline for submitting comments is January 28, 2019.
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.
Journal Article > Review
Joseph A, Henriksen K, Malone E. Health Aff (Millwood). 2018;37:1884-1891.
The built environment influences the safety and effectiveness of care delivery. This narrative review examines how care facility design can reduce health care–associated infections, falls, and medication errors. The authors provide suggestions regarding a range of facility design strategies and discuss how accreditation, funding, and policy organizations can support design projects as improvement efforts.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
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.
Journal Article > Study
Splinter K, Adams DR, Bacino CA, et al; Undiagnosed Diseases Network. N Engl J Med. 2018;379:2131-2139.
Improving diagnosis remains a major focus within patient safety. For patients with rare diseases, diagnosis can often be delayed. Established in 2014 and funded by the National Institutes of Health, the Undiagnosed Diseases Network (UDN) applies a multidisciplinary approach to the most challenging diagnostic cases. Over a 20-month period, 601 out of 1519 patient cases were accepted by the UDN for evaluation. The authors report that of the 382 patients who underwent a complete evaluation, a diagnosis was identified in 132 patients.
Journal Article > Study
Mazurenko O, Richter J, Kazley AS, Ford E. J Patient Saf. 2018 Oct 10; [Epub ahead of print].
Prior research has shown that managers and leaders often have a more positive view of safety culture compared to frontline staff. Using data from the 2010–2011 AHRQ Medical Office Survey on Patient Safety Culture, researchers found that perceptions of safety climate differed across medical practice owners and frontline staff, with managers bearing ownership responsibility having the more favorable view.
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.
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.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.
This announcement highlights Agency for Healthcare Research and Quality funding opportunities for health services research to assess local, state, and system-level policy to address the opioid crisis, evaluate interventions to minimize opioid misuse, and understand the rapid increase in opioid-related hospitalizations.
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.
Journal Article > Commentary
Ricciardi R, Shofer M. J Nurs Care Qual. 2018;33:195-199.
In this commentary, Agency for Healthcare Research and Quality staff summarize how agency activities have evolved over time. The authors review AHRQ efforts to designed to understand and improve patient safety in outpatient environments, engage patients and families in care activities, and build learning communities.