Narrow Results Clear All
- Commentary 45
- Review 11
- Study 76
- Slideset 2
- Book/Report 102
- Legislation/Regulation 3
- Newspaper/Magazine Article 15
- Newsletter/Journal 5
- Special or Theme Issue 14
- Glossary 2
- Toolkit 39
- Web Resource 254
- Award 1
- Bibliography 1
- Clinical Guideline 2
- Grant 25
- Meeting/Conference 24
- Press Release/Announcement 17
- Communication Improvement 81
- Culture of Safety 75
Education and Training
- Simulators 10
- Students 1
Error Reporting and Analysis
- Error Reporting 47
Human Factors Engineering
- Checklists 10
- Legal and Policy Approaches 52
- Logistical Approaches 23
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 22
- Research Directions 9
- Specialization of Care 10
- Teamwork 27
- Clinical Information Systems 33
- Transparency and Accountability 1
- Device-related Complications 11
- Diagnostic Errors 12
- Discontinuities, Gaps, and Hand-Off Problems 42
- Drug shortages 1
- Fatigue and Sleep Deprivation 8
- Identification Errors 2
- Interruptions and distractions 3
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 49
- Nonsurgical Procedural Complications 5
- Overtreatment 1
- Psychological and Social Complications 10
- Second victims 1
- Surgical Complications 29
- Transfusion Complications 1
- Geriatrics 20
- Primary Care 24
- Internal Medicine 100
- Nursing 25
- Pharmacy 24
- Family Members and Caregivers 6
- Health Care Executives and Administrators 328
Health Care Providers
- Nurses 31
- Pharmacists 13
- Physicians 40
Non-Health Care Professionals
- Educators 24
- Media 1
- Patients 37
Search results for "Agency for Healthcare Research and Quality (AHRQ)"
- Agency for Healthcare Research and Quality (AHRQ)
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
GOLD is a searchable database of grants funded by the Agency for Healthcare Research and Quality (AHRQ).
Rockville, MD: United States Pharmacopeial Convention, Inc.; 2004.
This report provides an analysis of more than 235,000 records submitted by 570 participating facilities to Medmarx and also provides trend analyses for records submitted between 1999 and 2003. The report contains three technology-focused special topics: computer entry, computerized prescriber order entry—analysis performed in collaboration with the Agency for Healthcare Research and Quality (AHRQ)—and automated dispensing devices.
Jt Comm J Qual Saf. 2004;30:653-680.
Special issue highlighting the winners of the 2004 John Eisenberg Award, which included Lucian Leape, MD; Peter Pronovost, MD; Robert Wachter, MD, and Kaveh Shojania, MD; Major Danny Jaghab; and the University of Pittsburgh Medical Center McKeesport, McKeesport, Pennsylvania.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, and the Harvard School of Public Health; November 2004.
Five years after the Institute of Medicine's landmark report on medical errors, this survey assessed Americans' perceptions about the quality of health care, their awareness and reported usage of information in making their health care choices, and their experiences with their health care providers. A summary of the findings is provided, as well as a Webcast featuring experts discussing the survey results.
Agency for Healthcare Research and Quality.
E-newsletter issued periodically to make important patient safety news and information available. The E-newsletter features concise descriptions of findings from the Agency for Healthcare Research and Quality's (AHRQ) published research, announcements about new products and tools, as well as updates on initiatives, meetings, and other key developments in the safety and quality field.
Web Resource > Database/Directory
Healthcare Cost and Utilization Project (HCUP).
This interactive tool identifies, tracks, analyzes, and compares statistics on hospital care. It is part of the Healthcare Cost and Utilization Project (HCUP). With HCUPnet, users gain easy access to all national and selected state statistics about hospital admissions. These statistics can provide insight into quality of care issues.
Kruzikas DT, Jiang HJ, Remus D, Barrett ML, Coffey RM, Andrews RA. Rockville, MD: Agency for Healthcare Research and Quality; September, 2004. AHRQ Publication No. 04-0056.
This Fact Book examines a critical area of health care quality: potentially preventable hospitalizations. Higher rates of "preventable hospitalizations" may identify areas for improvement within primary and preventive care.
Journal Article > Study
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. Health Aff (Millwood). 2004;23:202-212.
This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.
Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment.
Hsu EB, Jenckes MW, Catlett CL, et al. Summary, Evidence Report/Technology Assessment: Number 95. Rockville, MD: Agency for Healthcare Research and Quality; April 2004. AHRQ Publication Number 04-E015-1.
This report focuses on the effectiveness of hospital disaster drills, computer simulations, and tabletop or similar exercises in training hospital staff to respond to a mass casualty incident (MCI).
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.
Wachter and Shojania adapted many of the cases they previously published in the academic literature, some cases previously described in the lay literature (eg, the Duke transplant mix-up and the death of Betsy Lehman at Dana-Farber Cancer Institute), and other cases never previously reported to provide a dramatic account of medical errors and the field of patient safety. Dr. Lucian Leape wrote that Internal Bleeding "shows how cognitive psychology and human factors engineering provide the way out by shifting attention from blaming individuals to fixing faulty systems." The book, now in its fourth printing, continues to be a popular choice for anyone with an interest in patient safety.
Journal Article > Study
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
Zhan C, Miller MR. JAMA. 2003;290:1868-1874.
Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Journal Article > Commentary
Clancy CM, Scully T. Health Aff (Millwood). 2003;22:113-115.
This commentary, written by leadership from the Agency for Healthcare and Research Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), shares the vision of how patient safety will be achieved through targeted federal initiatives. The authors discuss the shifting paradigm that must result in the way our health systems understand, learn from, and prevent errors. They discuss several strategies already in place to support the mission of their respective agencies "to support research, information, and partnerships to ensure that all Americans receive high-quality, safe, and efficient health care."
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Evidence Report/Technology Assessment: Number 74. Rockville, MD: Agency for Healthcare Research and Quality; March 2003. AHRQ Publication No. 03-E024.
This report summarizes existing scientific evidence on the role health care working conditions play in patient safety efforts.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2003.
This web-accessible database provides access to evidence-based quality measures and measure sets. The mission of the National Quality Measures Clearinghouse (NQMC) is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further their dissemination, implementation, and use in order to inform health care decisions.
Plsek P. Paper presented at: Accelerating Quality Improvement in Health Care Strategies to Speed the Diffusion of Evidence-Based Innovations; January 27-28, 2003; Washington, DC.
In discussing the complexities of health care, the author provides insights into how this complexity creates challenges to the blunt end process of medicine. This impacts health care's ability to spread and support innovation.
Tools/Toolkit > Fact Sheet/FAQs
Patient Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; September 2002. AHRQ Publication No. 02-P034.
This consumer fact sheet advises parents on how to help their children avoid medical errors pertaining to medicine, hospital stays, surgeries, and other medical needs.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.