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- Communication Improvement 1
- Culture of Safety 10
- Education and Training 4
- Error Reporting and Analysis 5
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 10
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Health Care Executives and Administrators 19
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 8
- Patients 1
Search results for "Long-Term Care"
- Long-Term Care
- United States Federal Government
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Legislation/Regulation > Government Resource
Medicare and Medicaid programs; reform of requirements for long-term care facilities; proposed rule.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Centers for Medicare & Medicaid Services. July 16, 2015;80:42167-42269.
Poor safety culture and lack of available resources to provide high-quality care can hinder safety in long-term care facilities. This set of regulations will revise requirements for long-term care facilities in areas such as clinical practice standards, service delivery, patient-centeredness, and infection control. The deadline for officially submitting comments on the proposed rule was September 14, 2015.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; February 2014. Report No. OEI-06-11-00370.
This report from the Office of the Inspector General examines the nationwide incidence of adverse events in skilled nursing facilities among the Medicare population. Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event, and more than half were preventable. These results mirror previous studies documenting an overall poor level of safety culture in nursing homes. More than half of those who experienced harm were readmitted to the hospital. The report outlines recommendations, including raising awareness of safety concerns in this setting and instructing surveyors who inspect nursing homes to evaluate patient safety practices. These findings emphasize the importance of focusing outside acute care settings in order to advance patient safety by improving systems of care and by aligning accreditation and payment structures. A past AHRQ WebM&M interview discussed unique issues surrounding patient safety in the nursing home population.
Web Resource > Government Resource
Atlanta, GA: Centers for Disease Control and Prevention.
This Web site provides information about government initiatives to research and prevent health care–associated infections.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing and a tendency to blame individuals for problems. This website hosts the AHRQ survey for nursing homes along with additional materials to assist organizations in using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient safety in a nursing home and report the results. The resource provides guidance on topics such as data collection, data organization, survey forms, and nursing home staff selection.
Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.
Washington, DC: United States Government Accountability Office; 2005. Report No. GAO-06-117.
This report shares findings from a 5-year review of nursing home quality and safety, which revealed inconsistencies in state surveys that affect the government's ability to adequately address problems in care.
Web Resource > Database/Directory
Centers for Medicare and Medicaid Services.
This website provides consumers with detailed information about the past performance of every Medicare- and Medicaid-certified nursing home in the country. Additional resources available at the site help with other nursing home selection issues. Information is provided in English, Spanish, and Chinese.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in the nursing home setting. The 2016 user comparative database report summarizes survey data obtained from 12,395 staff and provider respondents working in 209 nursing homes. The report highlights two areas of safety culture in which nursing homes appear to do well: overall perceptions of resident safety and feedback and communication about incidents. Areas identified as needing improvement across most nursing homes included staffing issues and ensuring a nonpunitive response to mistakes. A previous PSNet perspective provided insights on safety culture.
Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-EHC022-EF.
Efforts to maintain patient autonomy can detract from ensuring residents' safety in nursing homes. Common safety issues in nursing homes are medication errors, falls, and inappropriate use of restraints. This technical brief discusses gaps in the research base that hinder understanding of the safety hazards in the residential care environment.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
Grant > Government Resource
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services. August 25, 2015. Program Announcement No. PA-15-339.
Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0001.
This set of training materials provides techniques to help improve staff monitoring of nursing home residents' conditions to prevent delays and minimize harm.
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0071.
Developed by the Agency for Healthcare Research and Quality (AHRQ), the Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. The survey expanded on the original hospital-based survey. Similar to that tool, AHRQ now provides annual comparative reports that present benchmarking data for safety culture across different regions, facility types, and staff positions. This edition shares data from 226 nursing homes and more than 16,000 staff. Notable findings include widespread concern about punitive responses to mistakes and safety concerns about poor staffing. An AHRQ WebM&M commentary discussed quality and safety issues in the nursing home setting.
Journal Article > Study
Kallen AJ, Mu Y, Bulens S, et al; Active Bacterial Core surveillance (ABCs) MRSA Investigators of the Emerging Infections Program. JAMA. 2010;304:641-648.
Journal Article > Study
Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.
Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.
Prior studies have documented suboptimal safety culture in long-term care facilities. This AHRQ-funded study used surveys and interviews to examine one specific aspect of safety culture—communication between nurses and physicians. Nurses noted several problems with communication, including lack of receptiveness by physicians and difficulty reaching physicians. Many nurses noted instances of unprofessional or disruptive behavior by physicians. Nurses acknowledged the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this AHRQ WebM&M commentary.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.