Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety 5
- Education and Training 5
- Error Reporting and Analysis 3
- Human Factors Engineering 2
- Legal and Policy Approaches 4
- Logistical Approaches 4
- Quality Improvement Strategies 7
- Research Directions 1
- Teamwork 1
- Technologic Approaches 9
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 6
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 4
- Overtreatment 1
- Psychological and Social Complications 2
- Surgical Complications 1
- Surgery 1
- Pharmacy 4
- Family Members and Caregivers 1
- Health Care Executives and Administrators 20
- Health Care Providers 21
- Non-Health Care Professionals 14
Search results for "Department of Health and Human Services (HHS)"
- Department of Health and Human Services (HHS)
- Primary Care
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Journal Article > Study
Kwan BM, Fernald D, Ferrarone P, et al. J Am Board Fam Med. 2019;32:136-145.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.
Journal Article > Commentary
National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use.
Ducoffe AR, York A, Hu DJ, Perfetto D, Kerns RD. Pain Med. 2016;17:2291-2304.
Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.
Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
The primary focus on patient safety research has been in the hospital environment, but the majority of care is delivered in the ambulatory setting. This technical brief discusses the existing evidence on hospital-based safety interventions that have the potential to be implemented in ambulatory care. Strategies with moderate evidence include e-prescribing, pharmacist involvement, and hospital-to-ambulatory care transitions.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.
For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Journal Article > Study
Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.
Hickner J, Smith SA, Yount N, Sorra J. BMJ Qual Saf. 2016;25:588-594.
Studies of safety culture have consistently found that management has more positive perceptions of safety than frontline workers. This analysis of data from the AHRQ Medical Office Survey on Patient Safety Culture explored this finding in greater depth. The study examines the specific areas where perceptions of safety diverged between medical office management, physicians, and staff from more than 800 clinics. The investigators found that staff (including physicians and nurses) had markedly lower perceptions of the quality of staff training in patient safety and the openness of communication around safety issues compared with management. Consistent with other studies, management also had a much higher perception of overall safety than staff. As high reliability organizations rely on shared goals and open communication to ensure situational awareness, variations in perceptions of safety culture across professional roles will impair an organization's ability to address safety issues.
Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.
Web Resource > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality.
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.
Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
Advocate Redi-Code+ blood glucose test strips by Diabetic Supply of Suncoast: recall—labeling error.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; June 11, 2014.
This announcement describes a recall of blood glucose test strips due to missing information on the label that could result in accidental misuse of test strips and potential delays in diagnosis and treatment of hyper- or hypoglycemia.
Web Resource > Multi-use Website
Massachusetts Department of Public Health.
The majority of early patient safety interventions focused on the hospital setting, but there is a growing determination to improve safety practices across the ambulatory sphere as well. This AHRQ-funded project, Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction (PROMISES), created a collaborative learning network of Massachusetts primary care practices and patient safety leaders. Program coaches visited 16 pilot primary care offices and worked directly with improvement teams to implement safe practices. The project also includes a report from physicians, malpractice insurers, and policy experts translating the hospital-based consensus statement, "When Things Go Wrong," into clear recommendations for ambulatory adverse events. The Web site provides various materials, including recorded lectures, case study videos, and tools to assist individuals and teams with enhancing outpatient safety. A past AHRQ WebM&M perspective explored patient safety in the office setting.
Rockville, MD: Agency for Healthcare Research and Quality; August 2013. AHRQ Publication No. 13-0067-EF.
This report summarizes findings from projects that explored how health information technology can augment quality and safety in ambulatory care.
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.
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Kohn LT. Washington, DC: United States Government Accountability Office; July 2012. Publication GAO-12-712.