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- Study 1
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- Newspaper/Magazine Article 5
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- Communication Improvement 5
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- Error Reporting and Analysis 5
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- Legal and Policy Approaches 1
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- Quality Improvement Strategies 11
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- Internal Medicine
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- Quality and Safety Professionals
- Health Care Providers 16
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 19
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Search results for "Quality and Safety Professionals"
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
Web Resource > Government Resource
Centers for Disease Control and Prevention, Safe Injection Practices Coalition.
This program raises awareness of safe injection practices and provides materials to engage staff and patients in improvement efforts.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Tools/Toolkit > Government Resource
Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.
Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0042-EF.
This report describes the state of currently available resources to promote patient and family engagement in their health care.
Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.
This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.
CDC Vital Signs. March 2012:1-4.
This newsletter article and accompanying set of infographics describes strategies to help patients and health care providers prevent health care–associated infections.
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.
O'Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2011;52:e162-e193.
This article discusses strategies to prevent catheter-related infections.
Rockville, MD: Agency for Healthcare Research and Quality; November 3, 2010. Publication No. NOT-HS-11-002.
This announcement describes funding opportunities for research on health care–associated infections.
New dosing recommendations to prevent potential Valcyte (valganciclovir) overdose in pediatric transplant patients.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 15, 2010.
This announcement describes revised dosing recommendations designed to prevent overdosing immunocompromised pediatric patients.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
This alert notifies health care providers of the potential for patient harm if a particular inhalation powder is reconstituted and incorrectly administered.