Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 3
- Education and Training 2
- Error Reporting and Analysis 11
- Human Factors Engineering 3
- Legal and Policy Approaches 5
- Logistical Approaches 1
- Quality Improvement Strategies 16
- Research Directions 1
- Teamwork 1
- Technologic Approaches 6
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 3
- Identification Errors 3
- Medical Complications 5
- Medication Safety 9
- Nonsurgical Procedural Complications 1
- Surgical Complications 2
- Family Members and Caregivers 1
Health Care Executives and Administrators
- Quality and Safety Professionals
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 1
- Patients 4
- Australia and New Zealand 1
- Europe 3
- United States of America 32
Search results for "Quality and Safety Professionals"
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.
Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.
Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.
Despite the reduction of drug shortages in recent years, access to certain types of drugs, such as generic sterile injectable medications, remains limited. Analyzing data on drug shortages in the United States, this government report identifies factors that contribute to shortages and suggests prioritizing efforts to address the most pressing problems including suppliers that fail to comply with standards.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF.
The growing interest in patient safety in ambulatory care led to the development of the AHRQ Medical Office Survey on Patient Safety Culture, which is designed to assess safety culture in outpatient clinics. This second comparative database report—a prior report was published in 2012—provides descriptive results and benchmarking data derived from more than 27,000 respondents (including clinical and support staff) from 935 clinics. The report identifies several areas of strength: 83% of offices reported having fully implemented electronic medical records, and respondents described high levels of teamwork as well as reliable patient tracking and test follow-up systems. However, as was also found in the 2012 report, many offices reported safety concerns relating to production pressures. The database is freely available from AHRQ for benchmarking and comparison purposes.
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC: Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
This report evaluates the implementation of a quality improvement initiative designed to characterize, track, and mitigate adverse events related to health information technology (IT). Investigators sought to determine challenges to engaging in identifying and addressing safety risks related to health IT in 11 health care organizations, and this publication outlines experiences and lessons learned from participating institutions. The authors call for greater awareness of safety risks related to health IT, better cooperation between risk management and health IT departments, identification of safety measures for health IT, incentives for health IT developers and vendors to improve health IT safety, and increased investment in risk management, health IT, and safety in ambulatory settings. The recommendations in this report serve as a blueprint for future practice and policy efforts to augment safety in the era of electronic health records.
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.
Alexandria, VA: Department of Defense, Office of the Inspector General; February 21, 2014. Report No. DODIG-2014-040.
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Washington, DC: United States Government Accountability Office; February 10, 2014. Publication GAO-14-194.
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.
This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Shekelle PG, Wachter RM, Pronovost PJ, eds. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 13-E001-EF.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
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.
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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; October 2011. Report No. OEI-01-08-00590.
The Office of the Inspector General (OIG) has conducted a series of analyses of adverse event incidence among Medicare beneficiaries. This report evaluates how hospitals, the Centers for Medicare and Medicaid Services (CMS), and state agencies have responded to particularly serious adverse events. The OIG found that investigations into errors were generally timely and resulted in changes with the potential to improve patient safety. However, the OIG faults state agencies for failing to communicate findings to The Joint Commission and for failing to monitor long-term safety performance at hospitals where errors occurred. The report outlines specific recommendations for CMS and state agencies to ensure that lasting safety improvement comes about after serious errors occur.
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.
Berkman ND, Sheridan SL, Donahue KE, et al. Evidence Report/Technology Assessment: Number 199. Rockville, MD: Agency for Healthcare Research and Quality; March 2011. AHRQ Publication No. 11-E006.
This evidence report updates a 2004 study to reveal how health literacy affects health outcomes.