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Search results for "General Internal Medicine"
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.
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013.
This white paper details how health care organizations can identify health information technology concerns and improve systems to reduce risks.
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Golden, CO: Healthgrades; 2013.
This analysis of Medicare hospitalization data from 2009–2011 highlights hospital efforts to drive safety improvement but notes that more than 280,000 preventable patient safety events occurred. The report also recognizes 379 hospitals with a Patient Safety Excellence Award for 2013.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092.
This report built on earlier research to examine rates of adverse events reported to state-level reporting systems compared with hospital data. It found that, even in states with required hospital reporting of adverse events, only about one in nine events is reported to the state. Because few of the events were found in each hospital's incident reporting system, the investigators concluded that the low rate of reporting was likely due to hospital failure to identify events rather than hospitals failing to report known events.
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Kohn LT. Washington, DC: United States Government Accountability Office; July 2012. Publication GAO-12-712.
Sorra J, Famolaro T, Dyer N, Smith S, Liu H, Ragan M. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0052.
The Agency for Healthcare Research and Quality's (AHRQ) Medical Office Survey on Patient Safety Culture is designed to assess safety culture in outpatient clinics. This inaugural database describes survey results from more than 23,000 respondents (including both clinical and administrative staff) from 934 participating offices. Notable results include generally positive perceptions of teamwork and patient tracking, but the majority of respondents felt that production pressures adversely affected safety. The database is freely available from AHRQ for benchmarking and comparison purposes, as is the Hospital Survey on Patient Safety Culture database.
Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0042-EF.
This report describes the state of currently available resources to promote patient and family engagement in their health care.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2012. Report No. OEI-06-09-00091.
Incident reporting systems are ubiquitous, but their effectiveness as a means of monitoring for patient safety problems is unclear. In a prior report, the Office of the Inspector General (OIG) found that 13.5% of Medicare beneficiaries suffered an adverse event while hospitalized. This follow-up analysis found that incident reports were not filed for the vast majority of these adverse events. Moreover, hospital personnel did not voluntarily report any of the never events identified in the earlier study. The reasons for this lack of reporting likely include confusion about which types of errors needed to be reported, as well as other issues documented in prior studies such as lack of reporting by physicians. Based on these findings, the OIG recommends that the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services (CMS) create a uniform list of potentially reportable events for dissemination to hospitals, and that CMS should assist accrediting agencies in assessing the adequacy of hospitals' error reporting systems.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
McAlearney AS, Song P, Garman A, McHugh M, Caputo N. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0080-EF.
Reporting on results from a multi-method investigation, this publication describes how implementation of high-performance work systems in human resources for the health care setting can impact patient outcomes.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0030.
The fifth annual edition of the AHRQ Hospital Survey on Patient Safety Culture comparative database presents benchmarking data for safety culture from more than 1000 hospitals nationwide, including trending data on changes in safety culture perception over time for more than 500 hospitals. The full report contains detailed comparative data for various hospital characteristics (type and size) and respondent characteristics (work areas, staff positions, and direct patient contact). Overall perception of safety culture improved compared with prior reports, and respondents specifically noted improvements in teamwork and management support of safety. However, persistent concerns were voiced about the safety of handoffs, and most respondents did not voluntarily report safety incidents.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.