Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 4
- Education and Training 4
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 7
- Teamwork 2
- Technologic Approaches 3
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 5
- Health Care Executives and Administrators 31
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 8
Search results for "Agency for Healthcare Research and Quality (AHRQ)"
- Agency for Healthcare Research and Quality (AHRQ)
- Error Analysis
Wachter RM. National Quality Measures Clearinghouse: Expert Commentaries; March 3, 2008.
This commentary describes how the focus on measurement in health care has affected both quality and safety initiatives.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.
Journal Article > Study
Encinosa WE, Bernard DM. Inquiry. 2005;42:60–72.
This AHRQ–funded study examined the relationship between hospital profit margins and the rate of patient safety events. Using data from 176 acute care hospitals in Florida, investigators categorized hospitals into four tiers based on their reported profit margins and compared event rates from more than one million surgical hospitalizations. Findings illustrated an inverse relationship, with the highest event rate occurring in hospitals with the lowest margins. The authors suggest that growing financial constraints may limit a hospital's investment in patient safety, leading to greater numbers of adverse events.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; April 2005.
On April 4, 2005, AHRQ hosted "Improving Health Care for All Americans: Celebrating Success, Measuring Progress, Moving Forward." The meeting showcased successful efforts to improve health care quality and reduce racial and ethnic disparities.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Adverse drug events (ADEs) are common and can result in patient harm. This report analyzes data from the Healthcare Cost and Utilization Project to compare characteristics of hospital inpatient stays involving an ADE from 2010 and 2014. Information revealed by the data include impacts on length of stay, average costs, and whether the ADE occurred in the hospital or prior to admission.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test interventions for managing and reducing burnout in the care environment. Key findings include the high prevalence of burnout among United States clinicians and the identification of factors that contribute to burnout, such as short visits, complicated patients, and electronic health record stress. The report also outlines interventions that require additional testing to effectively reduce clinician burnout. An Annual Perspective discussed the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.
Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.
Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
The primary focus on patient safety research has been in the hospital environment, but the majority of care is delivered in the ambulatory setting. This technical brief discusses the existing evidence on hospital-based safety interventions that have the potential to be implemented in ambulatory care. Strategies with moderate evidence include e-prescribing, pharmacist involvement, and hospital-to-ambulatory care transitions.
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
Recently, diagnostic error has garnered much discussion and examination, but further research is needed to understand and track such errors. This article reviews evidence on the topic to illustrate measurement challenges and includes a sociotechnical model to identify, assess, and address diagnostic errors.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
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.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Journal Article > Study
Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.
The financial costs associated with medical errors have gained increasing attention, due to the Centers for Medicare and Medicaid Services policy of nonpayment for certain preventable adverse events. This study sought to estimate costs associated with adverse events (measured by the Agency for Healthcare Research and Quality's Patient Safety Indicators) in surgical patients. Importantly, by measuring costs for a 90-day period after surgery, the authors were able to estimate the postdischarge financial impact of adverse events. Up to 20% of costs were incurred after hospital discharge, and the investigators found significant impact of adverse events on mortality and hospital readmissions. The implications of this study and prior research in this area help formulate a business case for safety.
Journal Article > Study
Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects.
Slonim AD, Marcin JP, Turenne W, Hall M, Joseph JG. Health Serv Res. 2007;42:2275-2293.
Journal Article > Study
Singh H, Thomas EJ, Petersen LA, Studdert DM. Arch Intern Med. 2007;167:2030-2036.
This AHRQ-funded study uncovered distinctive features of errors involving trainees, including teamwork and communication breakdowns, failures of supervision and handoffs, and excessive workload. Building on a past study of closed malpractice claims, investigators conducted a subanalysis of those claims in which housestaff or fellows were thought to play an important role. As the claims predate the introduction of trainee work hour restrictions, the authors call for continued research into trainee errors and targeted training interventions to address current areas of concern. An accompanying editorial discusses a dramatically new model for inpatient care that would begin to address the problem areas identified in this study.