Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 9
- Education and Training 7
- Error Reporting and Analysis 24
- Human Factors Engineering 1
- Legal and Policy Approaches 8
- Logistical Approaches 4
- Quality Improvement Strategies 15
- Research Directions 2
- Specialization of Care 1
- Teamwork 6
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 3
- Medical Complications 12
- Medication Safety 7
- Psychological and Social Complications 1
- Surgical Complications 4
- Health Care Executives and Administrators 41
Health Care Providers
- Nurses 3
- Non-Health Care Professionals 20
- United States of America
Search results for "Department of Health and Human Services (HHS)"
- Department of Health and Human Services (HHS)
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
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.
Journal Article > Government Resource
Rudd RA, Seth P, David F, Scholl L. MMWR Morb Mortal Wkly Rep. 2016;65:1445-1452.
Opioid medications are frequently associated with adverse drug events in inpatient and outpatient settings. This surveillance report from the Centers for Disease Control and Prevention demonstrated that the magnitude of patient harm from opioid use is growing rapidly. Opioid overdose deaths are increasing each year, through 2015, and current rates are the highest ever recorded. The types of opioids most commonly involved in overdose deaths are natural and semisynthetic opioids, which are often prescribed as pain relievers. The authors suggest that the adoption of new prescribing guidelines and more widespread use of the opioid reversal agent naloxone will help address this growing epidemic. An earlier version of this article included data through 2014. A previous WebM&M commentary described a fatal opioid overdose.
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.
Journal Article > Commentary
Kronick R, Arnold S, Brady J. JAMA. 2016;316:489-490.
The publication of To Err Is Human in 1999 drew national attention to the issue of patient safety and is often credited with catalyzing widespread efforts to reduce health care–related harm. At the time of the report's publication, central line–associated bloodstream infections (CLABSIs) were considered unpreventable. However, subsequent public reporting programs and the trend toward nonpayment for preventable harm have led not only to a significant reduction in CLABSIs, but a decrease in other types of hospital-acquired conditions as well. This directly translates into improved patient outcomes and reduced health care costs. This commentary highlights progress made in patient safety and suggests that future efforts should focus on improving the measurement of adverse events and mitigating diagnostic error. A past PSNet perspective discussed the evolution of patient safety as it relates to surgery.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Journal Article > Review
Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.
Winters BD, Bharmal A, Wilson RF, et al. Med Care. 2016;54:1105-1111.
The ability to use administrative data to measure patient safety is critical, because chart review is time-consuming and resource-intensive. The AHRQ Patient Safety Indicators (PSIs) and the CMS Hospital-acquired Conditions (HACs) aim to measure and track patient safety using administrative data. PSIs are often used for pay-for-performance, and CMS has a policy of nonpayment for hospitalizations associated with HACs. This systematic review found that PSIs and HACs have not been adequately validated compared to chart review and therefore may be subject to coding error. Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety efforts. These results suggest that unless further development and validation of administrative metrics occurs, widespread implementation of pay-for-performance efforts may not significantly improve patient safety.
Tools/Toolkit > Multi-use Website
Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
Journal Article > Study
Geller AI, Shehab N, Weidle NJ, et al. N Engl J Med. 2015;373:1531-1540.
Dietary supplements can cause harm, especially in combination with prescribed medication, and their use is increasing. This report from an established surveillance system sampled emergency department visits related to dietary supplements. The results suggest that adverse events related to dietary supplements cause 23,000 emergency department visits per year in the United States. Ingestions by unsupervised children accounted for nearly a quarter of the visits. Other common events included palpitations, chest pain, or tachycardia related to weight loss or energy supplements. The authors note that there is no legal requirement for supplement manufacturers to identify potential adverse effects on the products themselves, and they encourage clinicians to educate patients about potential adverse reactions.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; February 2014. Report No. OEI-06-11-00370.
This report from the Office of the Inspector General examines the nationwide incidence of adverse events in skilled nursing facilities among the Medicare population. Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event, and more than half were preventable. These results mirror previous studies documenting an overall poor level of safety culture in nursing homes. More than half of those who experienced harm were readmitted to the hospital. The report outlines recommendations, including raising awareness of safety concerns in this setting and instructing surveyors who inspect nursing homes to evaluate patient safety practices. These findings emphasize the importance of focusing outside acute care settings in order to advance patient safety by improving systems of care and by aligning accreditation and payment structures. A past AHRQ WebM&M interview discussed unique issues surrounding patient safety in the nursing home population.
Journal Article > Study
Wang Y, Eldridge N. Metersky ML, et al. N Engl J Med. 2014;370:341-351.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
Special or Theme Issue
Making Health Care Safer: A Critical Review of Modern Evidence Supporting Strategies to Improve Patient Safety.
Shekelle PG, Pronovost PJ, Wachter RM, Rao JK, Mulrow CD, eds. Ann Intern Med. 2013;158(5 Pt 2):365-440.
In 12 years since the seminal AHRQ Making Health Care Safer report was issued, research in the patient safety field has grown considerably, yielding a much stronger evidence base for preventing some types of errors. However, the literature also shows examples of many interventions that were strongly touted initially, but whose early successes could not be replicated. The systematic reviews in this special supplement—released in conjunction with the new AHRQ report, Making Health Care Safer II, from which these reviews are derived—critically examine the evidence supporting 10 patient safety practices, including methods to prevent particularly common adverse events such as diagnostic errors, adverse events after hospital discharge, and medication errors. Even after a decade of research into patient safety strategies, relatively few strategies are strongly supported by evidence. Thus, this supplement highlights "the continuing tension between needing to improve care and knowing how to do it." By explicitly considering the role of intervention cost, ease of implementation, and the effect of context on intervention success, the reviews attempt to help policymakers and safety professionals make decisions around how to improve safety in the face of limited or equivocal evidence.
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Shekelle PG, Wachter RM, Pronovost PJ, eds. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 13-E001-EF.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Journal Article > Study
Lee GM, Kleinman K, Soumerai SB, et al. N Engl J Med. 2012;367:1428-1437.
In 2008, the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors and hospital-acquired infections. This landmark policy aimed to align financial disincentives with adverse events, an increasingly utilized strategy. However, this AHRQ-funded study found that the "no pay for errors" policy had no measurable effect on rates of catheter–associated bloodstream infections and catheter–associated urinary tract infections in hospitals in the United States. No subgroup of hospitals or patients identified in this national evaluation seemed to clearly benefit from this policy change. The benefits and limitations of the CMS policy are discussed in an AHRQ WebM&M interview with Dr. Robert Wachter.