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- Study 1
- Audiovisual 1
- Book/Report 10
- Legislation/Regulation 2
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- Special or Theme Issue 1
- Toolkit 2
- Web Resource 16
- Communication Improvement 3
- Education and Training 3
- Error Reporting and Analysis 5
- Human Factors Engineering 5
- Legal and Policy Approaches 2
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Health Care Providers
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Search results for "Latent Errors"
Web Resource > Course Material/Curriculum
Rockville, MD: Agency for Healthcare Research and Quality; September 2015.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Publication 00-PO58.
This fact sheet on medical errors provides information based on current research. Patients at risk, types of medical errors, and ways to improve and promote patient safety are discussed. References to programs and publications on medical errors and patient safety are provided.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Audiovisual > Audiovisual Presentation
Agency for Healthcare Research and Quality.
This online education program will present both group-focused and self-paced opportunities for participants to learn how to apply TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
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.
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.
This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Tools/Toolkit > Government Resource
The Patient Education Materials Assessment Tool (PEMAT) and User's Guide: An Instrument to Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials.
Rockville, MD: Agency for Healthcare Research and Quality; October 2013.
This tool offers a method to assess patients' ability to understand and use education materials, including audiovisual and print formats.
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.
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
This report from the Department of Health and Human Services (HHS) describes a plan to bolster implementation of health information technology (IT) and reduce risks associated with its use. Building on recommendations of the Institute of Medicine report, Health IT and Patient Safety, the plan includes specific action items for HHS organizations and the private sector to augment health IT safety. Responsibilities will be shared across a number of HHS organizations: the Office of the National Coordinator (ONC), the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services. Goals involve making it easier for clinicians to report health IT–related incidents and hazards, encouraging reporting to Patient Safety Organizations, supporting the use of standardized forms in hospital incident reporting systems, and training surveyors to identify safe and unsafe practices associated with health IT. The Joint Commission has also contracted with ONC to better detect and address potential health IT–related safety issues across health care settings.
Legislation/Regulation > Government Resource
Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Draft Guidance.
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; April 24, 2013.
This draft guidance seeks to outline design elements that reduce errors associated with medication labels. The process for submitting public comments is now closed.
Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: The National Academies Press; 2012. ISBN: 9780309256810.
This report details the results of a workshop on health literacy in health care organizations.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
This Web site provides information associated with a software tool to identify and prevent hazards from health information technology use.
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.
Journal Article > Study
Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems.
Tucker AL, Singer SJ, Hayes JE, Falwell A. Health Serv Res. 2008;43:1807-1829.
Epidemiologic studies of adverse events in hospitals generally focus on identifying the incidence of errors and the most common types. This AHRQ-funded study sought to identify underlying work factors that contributed to errors, by soliciting the perspectives of front-line providers. These opinions were obtained by having senior managers directly observe work systems, in a fashion similar to executive walk rounds. Front-line staff most commonly identified equipment problems and facility design problems as major contributors to errors, with staffing and communication issues also mentioned frequently. These human factors issues contribute to latent errors, and the authors suggest that equipment and facility problems deserve more attention in the quest to improve patient safety.
Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-P0020.
In this report, the author draws from multidisciplinary sources to share examples of practical process and design changes that can mitigate human error in health care.