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- Commentary 45
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- Study 76
- Slideset 2
- Book/Report 102
- Legislation/Regulation 3
- Newspaper/Magazine Article 15
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- Special or Theme Issue 14
- Glossary 2
- Toolkit 39
- Web Resource 254
- Award 1
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- Clinical Guideline 2
- Grant 25
- Meeting/Conference 24
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- 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
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- 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 "United States of America"
- Agency for Healthcare Research and Quality (AHRQ)
- United States of America
Meeting/Conference > Maryland Meeting/Conference
Johns Hopkins Armstrong Institute for Patient Safety and Quality. November 5-6, 2019; Constellation Energy Building, Baltimore, MD.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality.
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. This website provides data submitted from PSOs and other organizations in reports, chartbooks, and dashboards. These tools enable the wide dissemination of information to inform organizational improvement strategies.
Meeting/Conference > United States Meeting/Conference
AHA Team Training. June 27–November 5, 2019.
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
Journal Article > Study
Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.
Gampetro PJ, Segvich JP, Jordan N, Velsor-Friedrich B, Burkhart L. J Patient Saf. 2019 Mar 29; [Epub ahead of print].
Measuring hospital safety culture is supported by the Agency for Healthcare Research and Quality (AHRQ). Although the relationship between a strong safety culture and improved outcomes for patients is not well established in existing literature, developing a sound safety culture is considered important for patient safety. In this cross-sectional study using data from the AHRQ Survey on Hospital Patient Safety Culture, researchers sought to understand the perceptions of pediatric hospital safety culture among interprofessional health care providers working at 287 pediatric hospitals or units. In keeping with prior research, they found that perceptions of safety culture among pediatric professionals, including nurses, physician assistants/nurse practitioners, physicians, and hospital administrators, varied both within hospitals and units. The authors identified safety culture dimensions that could be targeted for improvement and determined that all four professional groups perceived a punitive work culture. A past PSNet perspective emphasized the importance of establishing a culture of safety.
Grant > Government Resource
US Department of Health and Human Services. Program Announcement No. RFA-HS-19-003.
Diagnostic error research is emerging as an area of focus in health care. This funding opportunity will support large research projects that seek to examine diagnostic processes and diagnostic errors in a variety of settings and patient populations. The deadline for submitting a letter of intent is April 22, 2019. The application due date is May 29, 2019.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Journal Article > Study
Kwan BM, Fernald D, Ferrarone P, et al. J Am Board Fam Med. 2019;32:136-145.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.
Journal Article > Commentary
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
Henriksen K, Rodrick D, Grace EN, Shofer M, Brady PJ. J Patient Saf. 2019 Feb 9; [Epub ahead of print].
Applying systems engineering strategies from problem analysis through postimplementation evaluation can lead to solutions grounded in actual practice and learning for individuals, teams, and organizations. This commentary discusses the Agency for Healthcare Research and Quality patient safety learning laboratories initiative. The authors, who serve as program officers and oversee the grants, review lessons learned through experiences of grantees.
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;45:231–240.
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 > Study
Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.
Davis KK, Mahishi V, Singal R, et al. J Clin Med Res. 2019;11:7-14.
Ambulatory surgery centers are increasingly utilized to provide surgical care to patients. Quality improvement approaches utilized in the inpatient setting may need to be modified or adapted to be applicable in the ambulatory surgery environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques across 665 ambulatory surgery centers recruited for the study. They identified several barriers and conclude that the unique aspects of ambulatory surgery centers must be taken into account when implementing quality improvement initiatives.
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.
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
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.
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.