Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety
Education and Training
- Students 1
- Error Reporting and Analysis 8
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Research Directions 2
- Teamwork 5
- Technologic Approaches 6
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Medical Complications 3
- Medication Safety 7
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Transfusion Complications 1
- Health Care Executives and Administrators 15
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 6
- Patients 1
Search results for "Education and Training"
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Tools, Methods, and Techniques for Improving Patient Safety: Patient Safety Improvement Corps Training DVD.
Rockville, MD: Agency for Healthcare Research and Quality; 2007.
This DVD provides training modules for health care professionals regarding systems-oriented, institutional improvements in patient safety.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
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.
Audiovisual > Audiovisual Presentation
Agency for Healthcare Research and Quality. November 9, 2016.
Journal Article > Review
Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Ann Intern Med. 2013;158(5 Pt 2):369-374.
This systematic review—part of the AHRQ Making Health Care Safer II report—found some evidence that interventions, such as teamwork training, executive walk rounds, and structured communications approaches, can improve safety culture, especially when bundled together as a multicomponent intervention.
Grant > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09-P013-4-E.
This announcement highlights projects funded by the Agency for Healthcare Research and Quality to reduce incidence of health care–associated infections.
Journal Article > Study
Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.
Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
Teamwork training programs have resulted in some notable successes, but many other attempts have failed to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in durable provider behavior change. In this AHRQ-funded study, the TeamSTEPPS training program was introduced in two intensive care units (one pediatric and one adult surgical), after meticulous preparatory planning that emphasized the utility of the training for frontline care providers, engaged higher-level support for the effort, and established clear metrics for effectiveness. The program resulted in improvement in directly observed team behaviors and measures of safety culture, and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork training interventions in the context of efforts to develop high reliability organizations.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Audiovisual > Meeting/Conference Proceedings
2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.
Agency for Healthcare Research and Quality. June 6-10, 2005.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2005. AHRQ Publication No. 05-P003-3.
This program brief summarizes patient safety research projects funded by the Agency for Healthcare Research and Quality (AHRQ) since 2001.
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.
Wachter and Shojania adapted many of the cases they previously published in the academic literature, some cases previously described in the lay literature (eg, the Duke transplant mix-up and the death of Betsy Lehman at Dana-Farber Cancer Institute), and other cases never previously reported to provide a dramatic account of medical errors and the field of patient safety. Dr. Lucian Leape wrote that Internal Bleeding "shows how cognitive psychology and human factors engineering provide the way out by shifting attention from blaming individuals to fixing faulty systems." The book, now in its fourth printing, continues to be a popular choice for anyone with an interest in patient safety.