Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 5
- Education and Training 7
- Error Reporting and Analysis 8
- Human Factors Engineering 3
- Legal and Policy Approaches 4
- Logistical Approaches 2
Quality Improvement Strategies
- Practice Guidelines
- Teamwork 2
- Technologic Approaches 6
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 1
- Identification Errors 2
- Medical Complications 6
- Medication Errors/Preventable Adverse Drug Events 8
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 7
- Internal Medicine 12
- Surgery 7
- Nursing 1
- Pharmacy 4
- Family Members and Caregivers 2
- Health Care Executives and Administrators 38
Health Care Providers
- Nurses 3
- Non-Health Care Professionals 11
- Patients 3
- Australia and New Zealand 1
- Europe 9
- Canada 1
Search results for "Practice Guidelines"
- Practice Guidelines
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
London, UK: Royal College of Surgeons of England; 2016.
National Quality Partners. Washington, DC: National Quality Forum; 2016.
Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
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.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0042-EF.
This report describes the state of currently available resources to promote patient and family engagement in their health care.
Atlanta, GA: Centers for Disease Control and Prevention; 2011.
This report suggests strategies to prevent infections in the outpatient setting and provides links to more detailed infection prevention information.
Windwick B, Aubin D, Beard P, et al; Disclosure Working Group. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2011. ISBN: 9781926541389.
These national guidelines for Canadian health care providers serve as a tool for developing and implementing disclosure policies, practices, and training methods.
Patankar MS, Brown JP, Treadwell MD. Aldershot, UK: Ashgate Publishing; 2005. ISBN: 9780754642473.
The authors review the ethical foundations of safety in the aviation, health care, and occupational and environmental health industries. The authors encourage professionals to embrace ethical decision making in supporting their safety work.
Horsham, PA: Institute for Safe Medication Practices; May 2017.
Insulin is a widely used medication that can contribute to serious patient harm if used incorrectly. This report provides information about problems associated with insulin use in adults and offers consensus-developed strategies to encourage subcutaneous insulin practices that reduce errors at the prescribing, pharmacy management, administration, and transition phases.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.
Horsham, PA: Institute for Safe Medication Practices; 2016.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.
Learning organizations are capable of addressing problems through information sharing and learning from past experience to facilitate improvement and innovation. Large system failure occurs when such interventions are not disseminated and implemented. This report discusses the need to ensure that lessons learned in military trauma care are acted on and sustained and recommends that this information be translated for the civilian health system as a way to reduce preventable patient harm in trauma care.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.