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- Study 21
- Slideset 2
- Book/Report 28
- Legislation/Regulation 1
- Newspaper/Magazine Article 3
- Newsletter/Journal 1
- Special or Theme Issue 2
- Tools/Toolkit 4
- Web Resource 50
- Grant 7
- Meeting/Conference 8
- Press Release/Announcement 5
- Communication Improvement 11
- Culture of Safety 14
Education and Training
- Students 1
- Error Reporting and Analysis 25
- Human Factors Engineering 12
- Legal and Policy Approaches 16
- Logistical Approaches 3
- Policies and Operations 1
- Quality Improvement Strategies 22
- Research Directions 6
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- Clinical Information Systems 34
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 9
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 21
- Psychological and Social Complications 3
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- Internal Medicine 18
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- Health Care Executives and Administrators
Health Care Providers
- Nurses 7
- Non-Health Care Professionals 65
- Patients 2
Search results for "Health Care Executives and Administrators"
- Department of Health and Human Services (HHS)
- Health Care Executives and Administrators
- Technologic Approaches
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.
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.
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.
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.
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
The Institute of Medicine called for enhanced transparency in the reporting of health IT safety incidents to inform implementation and use of such technologies. This report reviews insights from a multidisciplinary task force that discussed how to design an entity focused on improving health IT–related safety that enables collaboration and learning.
Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.
Journal Article > Study
Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.
Powers C, Gabriel MH, Encinosa W, Mostashari F, Bynum J. J Am Med Inform Assoc. 2015;22:1094-1098.
This analysis of Medicare data found that outpatient practices using electronic prescribing had fewer adverse drug events among their panel of patients with diabetes compared to practices not consistently using electronic prescribing. Although promising, this study does not address the many differences between practices that use electronic prescribing versus those that do not and the patients that select these disparate health care systems.
Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.
This investigation found that although use of electronic health records (EHRs) in Medicare and Medicaid programs increased between 2011 and 2012, EHR systems lack the ability to track quality and safety to measure improvements. The report recommends developing a comprehensive strategy to compile clinical quality measurement data.