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- Commentary 10
- Study 48
- Slideset 2
- Book/Report 33
- Legislation/Regulation 3
- Newspaper/Magazine Article 4
- Newsletter/Journal 1
- Special or Theme Issue 2
- Tools/Toolkit 4
- Web Resource 59
- Grant 7
- Meeting/Conference 10
- Press Release/Announcement 5
- Communication Improvement 19
- Culture of Safety 16
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 13
- Human Factors Engineering 15
- Legal and Policy Approaches 19
- Logistical Approaches 7
- Policies and Operations 1
- Quality Improvement Strategies 33
- Research Directions 6
- Specialization of Care 2
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- Clinical Information Systems 64
- Device-related Complications 1
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 21
- Fatigue and Sleep Deprivation 2
- Identification Errors 2
- Inpatient suicide 1
- Interruptions and distractions 1
- Medical Complications 7
- Medication Errors/Preventable Adverse Drug Events 30
- Psychological and Social Complications 3
- Surgical Complications 2
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- Internal Medicine 31
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- Health Care Executives and Administrators
Health Care Providers
- Nurses 9
- Non-Health Care Professionals 97
- Patients 3
Search results for "Health Care Executives and Administrators"
Tools/Toolkit > Government Resource
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators use hospital admissions data to screen for potential quality lapses on conditions that generally don't require hospitalization if managed effectively at the primary care level.
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
The introduction of information technology has transformed health care. This notice of intent from AHRQ announces an upcoming funding opportunity to support research exploring the adoption of interoperable information technologies to improve communication during transitions. The pending funding will help to refine and develop methods to assess implementation success.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Clinician burnout is a persistent threat to patient safety, and electronic health records have been identified as a high-profile contributor to the problem. This call for public comments on a draft report seeks insights on specific goals and recommended strategies to address the issue. The approaches outlined focus on reducing the time burden associated with frontline electronic health record use. The option for submitting comments is closed.
Journal Article > Commentary
U.S. Food and Drug Administration Precertification pilot program for digital health software: weighing the benefits and risks.
Lee TT, Kesselheim AS. Ann Intern Med. 2018;168:730-732.
Innovation is a valuable process in health care. However, when innovations are rapidly deployed, efforts to proactively identify and address safety concerns may fall short and lead to unintended consequences. This commentary describes a new program to expedite the review of digital health software and summarizes the benefits and potential harms that could result from the program.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
Health care has worked to enhance use of information technologies to improve efficiency and safety. This report highlights 151 AHRQ-funded projects focused on understanding how health care information technology can address clinician needs, support decision making, and increase patient access to electronic health records.
Journal Article > Study
Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.
Murphy DR, Meyer AND, Vaghani V, et al. J Am Coll Radiol. 2018;15:287-295.
Electronic triggers are critical tools for detecting adverse events, diagnostic errors, and other safety hazards. Researchers developed an electronic health record–based trigger tool to identify delays in abnormal mammogram follow-up at Veterans Affairs facilities. The tool was moderately effective in detecting diagnostic and treatment delays (positive predictive value 71%) and rarely failed to identify a delay (negative predictive value 93%). Inability to schedule timely follow-up and other systems issues were the most common sources of delay. This study is a rigorous example of how trigger tools can detect safety hazards and improve timely cancer diagnosis. A recent Annual Perspective describes how electronic health records can both help and hinder patient safety.
Journal Article > Study
Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.
Oliva EM, Bowe T, Tavakoli S, et al. Psychol Serv. 2017;14:34-49.
Opioid-related harm is an urgent patient safety priority. Identifying patients at higher risk of harm is a critical aspect of opioid safety. This quality improvement team developed a predictive model, based on electronic health record data, to identify high-risk opioid users in order to provide targeted monitoring and intervention via a clinical decision support tool. The model included known risk factors for opioid-related harm, such as type of medication, dose, and coprescribed sedating medications as well as medical and mental health conditions. Investigators developed and validated the model using data from 2010 and tested its ability to predict overdose or suicide attempt in 2011. The model successfully and prospectively identified patients at risk for suicide attempt or overdose. They then used the electronic health record to provide physicians with an overdose or suicide risk estimate and a checklist of risk mitigation strategies at the point of care. The authors suggest that further study of the implementation of this risk mitigation strategy in primary care is needed.
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.
Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.
Legislation/Regulation > Government Resource
Federal Register. Washington, DC: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2016;81:72404-72471.
Requirements are needed to manage risks associated with health information technology systems. This final rule provides a framework for government review of technologies certified by the ONC Health IT Certification Program. The rule also covers certification guidance for testing laboratories. The regulations go into effect December 19, 2016.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
Web Resource > Government Resource
Office of the National Coordinator for Health Information Technology.
Overdoses of opioid medications are considered an epidemic in the United States. This website provides access to various resources for hospitals and clinicians to help them address this patient safety concern. Sections include guidelines, clinical decision support, electronic prescribing, and prescription drug monitoring programs.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2016.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide range of patient safety resources collected by AHRQ, including a new section summarizing their involvement in understanding diagnostic error.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.
Journal Article > Study
Furukawa MF, Eldridge N, Wang Y, Metersky M. J Patient Saf. 2016 Feb 6; [Epub ahead of print].
Electronic health record (EHR) adoption was widely spurred by an assumption that it would improve patient safety. Although research suggests that EHRs have had an overall positive effect, unexpected consequences have occurred along the way and many problems remain. This retrospective study compared adverse events among patients in hospitals with fully electronic EHRs to those without such EHRs in place. After controlling for patient and hospital characteristics, patients exposed to a fully electronic EHR had 17% to 30% lower odds of having an adverse event. A recent PSNet interview with Dr. Robert Wachter discussed the role of health information technology in patient safety.
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.