Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis 4
- Legal and Policy Approaches 1
- Quality Improvement Strategies 4
- Technologic Approaches 1
- Health Care Executives and Administrators 12
- Health Care Providers 5
- Non-Health Care Professionals 7
Search results for "Geriatrics"
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.
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.
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
Telehealth is a rapidly expanding approach of adopting technology to deliver health care services and information that improves the quality, safety, access, efficiency, and costs of care. Although the evidence that telehealth achieves these aims is still lacking, this report outlines AHRQ's health information technology portfolio, which funded a number of programs to evaluate this promising technology and approach. The report findings are based on interviews with lead investigators. It discusses the scope of the projects funded, the technical challenges faced, the organizational and cultural issues encountered, and the opportunities ahead.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
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.
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015.
Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman IR. HCUP Statistical Brief #244. Rockville, MD: Agency for Healthcare Research and Quality; September 2018.
Polypharmacy, chronic conditions, and mental health needs can contribute to misuse of opioids. This data analysis from the AHRQ Healthcare Cost and Utilization Project found that opioid-related hospitalizations and emergency room visits for older Americans increased substantially between 2010 and 2015.
Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
Prior research has shown that safety culture is relatively poor among frontline workers in skilled nursing facilities. Trigger tools can help to identify opportunities for patient harm and measure adverse events that occur over time. This toolkit outlines steps to use a trigger tool in skilled nursing facilities, reviews types of events that take place in this setting, and discusses how to analyze trigger tool data to inform improvement work. A past WebM&M commentary discusses challenges to safety in long-term care.
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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
MacLennan PA, Owsley C, Rue LW III, McGwin G Jr. Washington, DC: American Automobile Association Foundation for Traffic Safety; August 2009.
This report provides results of a survey about older adults' awareness of common medications that may impair the ability to drive.
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.