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- Communication Improvement 2
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 3
Search results for "Education and Training"
Journal Article > Study
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019 Jan 10; [Epub ahead of print].
Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.
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.
Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
This special issue highlights an AHRQ-funded symposium on the role of simulation in medical education and covers topics such as teamwork training and skill improvement.
Web Resource > Multi-use Website
Center for Perioperative Research in Quality, Vanderbilt University.
This AHRQ-funded project supports interprofessional communications training for post-anesthesia care unit teams and targets nurse handoff improvements.
Journal Article > Study
Garbutt J, Brownstein DR, Klein EJ, et al. Arch Pediatr Adolesc Med. 2007;161:179-185.
Though medical errors are common in pediatric patients, to date few studies have examined pediatricians' attitudes toward errors. This AHRQ-funded study surveyed pediatric residents and attending physicians regarding their experiences with reporting medical errors. The majority of physicians had direct experience with errors and supported disclosing errors to patients and their parents, but only a minority had disclosed a serious error. Respondents expressed dissatisfaction with current means of reporting errors (eg, incident reporting systems) and expressed a desire for formal training in error disclosure. These findings are similar to those previously reported in physicians caring for adult patients.
Journal Article > Commentary
Development of a patient safety web-based education curriculum for physicians, nurses, and patients.
Hendee WR, Keating-Christensen C, Loh YH. J Patient Saf. 2005;1:90-99.