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- Communication Improvement 6
- Culture of Safety 13
- Education and Training 13
Error Reporting and Analysis
- Error Analysis 17
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- Human Factors Engineering 3
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- Quality Improvement Strategies 22
- Research Directions 2
- Specialization of Care 1
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- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 6
- Fatigue and Sleep Deprivation 4
- Identification Errors 1
- Medical Complications 14
- Medication Safety 11
- Psychological and Social Complications 1
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Health Care Providers
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United States of America
United States Federal Government
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Search results for "United States Federal Government"
- United States Federal Government
Journal Article > Study
Shah T, Patel-Teague S, Kroupa L, Meyer AND, Singh H. BMJ Qual Saf. 2019;28:10-14.
Alert fatigue associated with electronic health records (EHRs) contributes to primary care physician burnout and can increase medication errors. The phenomenon is especially well-described in the Veterans Affairs (VA) system, where providers receive more than 100 alerts per day, which require an average of 85 seconds to address. This study describes a nationwide VA initiative to reduce EHR alerts in primary care and teach providers to process alerts more efficiently. Alerts decreased by a small but significant amount—from an average of 128 per day to an average of 116 per day. Providers who received the most alerts before the initiative experienced the largest alert reduction. A PSNet perspective described a way forward in improving EHR safety.
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 > Commentary
Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.
Gellad WF, Good CB, Shulkin DJ. JAMA Intern Med. 2017;177:611-612.
Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This commentary discusses US Veterans Affairs health system initiatives that focus on education, prescription monitoring, pain management, and use of guidelines to reduce risks associated with opioids.
Journal Article > Study
Lin LA, Bohnert AS, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Pain. 2017;158:833-839.
Opioids are known to be high-risk medications, and unsafe prescribing practices are common. This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback to clinicians about high-risk opioid prescribing. Local champions implemented the dashboard tool and spearheaded safer opioid prescribing. Using an interrupted time series analysis, researchers determined that the intervention reduced two unsafe prescribing practices: high-dose opioid prescriptions and concurrent use of opioids and benzodiazepines. The authors suggest that this type of large-scale intervention could be applied in other health care systems to enhance opioid safety. A recent Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to foster safer opioid use.
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.
Journal Article > Study
Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.
Maguire EM, Bokhour BG, Asch SM, et al. Public Health. 2016;135:75-82.
Large-scale adverse events can diminish public trust. According to this qualitative analysis of print, broadcast, and social media reports associated with certain infection control lapses in the Veterans Affairs health system, media reports did not convey specific aspects of error disclosure, such as apologies and lessons learned. Investigators also found that comments from hospital officials focused on providing factual information, while quotes from elected officials were largely negative. This study highlights the continuing need to follow evidence-based disclosure practices when interacting with media after adverse events.
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.
Journal Article > Study
Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2016 Jan 7; [Epub ahead of print].
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
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.
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014). (Testimony of John James, PhD; Ashish Jha, MD, MPH; Tejal Gandhi, MD, MPH; Peter Pronovost, MD, PhD; Joanne Disch, PhD, RN; Lisa McGiffert.)
A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.