Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Quality Improvement Strategies
- Device-related Complications 2
- Interruptions and distractions 1
- Medication Errors/Preventable Adverse Drug Events 11
- MRI safety 1
Search results for "Department of Health and Human Services (HHS)"
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Journal Article > Study
Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.
Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.
This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.
Special or Theme Issue
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Journal Article > Study
Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement.
Zrelak PA, Utter GH, Sadeghi B, Cuny J, Baron R, Romano PS. J Nurs Care Qual. 2012;27:99-108.
This study describes how AHRQ Patient Safety Indicators may help identify improvement opportunities for nursing care, their documentation practices, and their role in driving system-level changes.
Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
This handbook prepared by the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation provides a comprehensive summary of important patient safety and quality improvement concepts for frontline nurses. Experts in each topic area reviewed the latest published evidence to assemble sections on providing patient-centered care, nurses' working conditions and work environment, critical opportunities for improving quality and safety, and practical tools for implementing patient safety interventions for practicing nurses.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.
This announcement alerts health care providers to the potential for life-threatening errors involving two heparin products and provides recommendations to minimize mistakes.
Food and Drug Administration (FDA) Patient Safety News. Show #60. February 2007.
This video segment shares recommendations for providers about safe prescribing of methadone for pain control, including heightened patient monitoring and encouraging patients to ask questions about how the drug will affect them.
Meeting/Conference > Government Resource
Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.
US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.
The US Food and Drug Administration invited experts to comment on how labels for intravenous drugs could be designed to ensure the safe use of these medications through informed label redesign efforts.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.
The Centers for Disease Control and Prevention (CDC) investigated adverse events related to cough and cold medications in infants. The investigation found three instances in which these medications were considered the underlying cause of death.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
FDA Alert for Healthcare Professionals [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration alert reminds health care professionals that nimodipine should only be administered orally, and that intravenous or parenteral administration can cause serious adverse events.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 14, 2005.
This announcement explains a labeling change (utilizing color branding to help prevent dispensing errors) to a commonly used form of insulin.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.
Journal Article > Commentary
Hughes RG, Edgerton EA. Am J Nurs. May 2005;105:79-84.
The authors present eight practical steps for nurses to take in preventing pediatric medication errors, paying particular attention to mathematical miscalculation.
Am J Nurs. March 2005;105(suppl 3):1-47.
The University of Pennsylvania School of Nursing, the Hospital of the University of Pennsylvania, the Infusion Nurses Society, and the American Journal of Nursing held an invitational symposium in Philadelphia on July 16-17, 2004. The goals of the symposium were to determine research priorities and to make clinical education and policy recommendations to ensure safe medication administration. The symposium, supported by a conference grant from the Agency for Healthcare Research and Quality (AHRQ 1 R13 HS14836-01) and by unrestricted grants from manufacturers of pharmaceuticals and other products designed to promote safe medication administration, was attended by 40 nursing and professional experts. This supplemental issue reports on the symposium proceedings.
Tools/Toolkit > Fact Sheet/FAQs
National Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. AHRQ Publication No. 04-P025.
This fact sheet presents 30 safe practices that can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all applicable health care settings to reduce the risk of harm to patients. The practices are derived from a 2003 consensus report developed by the National Quality Forum.
Journal Article > Study
Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.