Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 5
- Education and Training 3
- Error Reporting and Analysis 12
- Human Factors Engineering 1
- Legal and Policy Approaches 6
Quality Improvement Strategies
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 4
- Diagnostic Errors 1
- Identification Errors 3
- Medical Complications
- Medication Safety 5
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 9
- Transfusion Complications 1
Search results for "Benchmarking"
- Nosocomial Infections
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.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Journal Article > Study
Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353.
Health care–associated infections are common and the subject of wide-scale prevention programs, despite concerns about their use as a quality metric. This study used a national database to examine the clinical and economic costs attributed to the development of health care–associated sepsis and pneumonia. Analyzing nearly 600,000 cases, investigators found 2.3 million hospitalization days, $8.1 billion in in-hospital costs, and 48,000 preventable deaths attributed to health care–associated sepsis and pneumonia. They also reported at least 40% higher length of stay and costs in patients with these complications who underwent invasive procedures compared to those who did not. Despite limitations in utilizing administrative data to draw clinical details, the findings are notable. A related commentary [see link below] discusses reducing preventable harm in the context of this study's findings, calling for greater investments in the science of health care quality and safety.
Web Resource > Multi-use Website
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
Allegranzi B, Nejad SB, Castillejos GG, Kilpatrick C, Kelley E, Mathai E; Clean Care is Safer Care Team. Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507.
This report reviewed the literature on health care–associated infections and found it to be the most prevalent adverse event affecting patients worldwide.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Perspectives on Safety > Interview
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Journal Article > Study
Do the AHRQ Patient Safety Indicators flag conditions that are present at the time of hospital admission?
Bahl V, Thompson MA, Kau T-Y, Hu HM, Campbell DA Jr. Med Care. 2008;46:516-522.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) were designed to reflect the quality of inpatient care by triggering cases for review using administrative data and examining potentially preventable complications. With an increasing focus on withholding payment for complications of care not present on admission (POA), efforts to make this important distinction continue. This study applied the use of PSIs with and without a POA variable and discovered that event rates were significantly lower for five PSIs using the added variable (decubitus ulcer, foreign body left in, selected infections due to medical care, and postoperative derangements and thromboembolic events). These findings suggest that use of standard PSIs will overstate the number of hospital complications in failing to take into account those clearly POA. The authors conclude that unadjusted PSIs should not be used to profile hospital performance or determine reimbursement.
Journal Article > Commentary
Klompas M, Platt R. Ann Intern Med. 2007;147:803-805.
This commentary asserts that, until objective outcome measures are developed, ventilator-associated pneumonia rates should not be used as a measure to reward quality of care.
Wisc Med J. 2006:105;1-86.
This special issue includes articles on programs and initiatives to improve the safety of health care. It also includes proceedings from a 2006 Wisconsin conference on patient safety.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Commentary
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
High-reliability organizations (eg, the aviation industry) have developed methods for achieving safety despite hazardous conditions. This study describes the development of a framework to achieve high reliability in the intensive care unit (ICU) context and discusses its application to the problem of preventing catheter-related bloodstream infections. The framework is based on a previously published method for evaluating safety interventions; the key elements include selecting measurable outcomes, applying evidence-based interventions, ensuring the intervention reaches all patients, and improving the overall culture of safety. The investigators applied this approach in ICUs in Michigan and achieved significant reductions in the incidence of catheter-related bloodstream infections.
Journal Article > Study
Agoritsas T, Bovier PA, Perneger TV. J Gen Intern Med. 2005;20:922-928.
The authors surveyed adults recently discharged from a Swiss hospital and found that patients can effectively pinpoint in-hospital adverse events.
Cases & Commentaries
- Web M&M
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.