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- Agency for Healthcare Research and Quality (AHRQ)
- Specialized Teams
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.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Journal Article > Review
Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Ann Intern Med. 2013;158(5 Part 2):417-425.
Rapid response systems (RRSs) are somewhat effective at preventing cardiorespiratory arrest outside the intensive care unit, according to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal Medicine. The review also identifies barriers and facilitators to effective implementation of RRSs in different contexts.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
This special issue highlights an AHRQ-funded symposium on the role of simulation in medical education and covers topics such as teamwork training and skill improvement.