Narrow Results Clear All
- WebM&M Cases 4
- Perspectives on Safety 4
- Commentary 11
- Review 5
- Study 51
- Audiovisual 1
- Book/Report 24
- Legislation/Regulation 2
- Newspaper/Magazine Article 6
- Special or Theme Issue 3
- Toolkit 3
- Web Resource 16
- Meeting/Conference 3
- Press Release/Announcement 2
- Communication between Providers 14
- Culture of Safety 31
- Education and Training 10
Error Reporting and Analysis
- Error Reporting 17
- Human Factors Engineering 3
- Legal and Policy Approaches 20
- Logistical Approaches 7
Quality Improvement Strategies
- Specialization of Care 9
- Teamwork 12
- Technologic Approaches 11
- Device-related Complications 4
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 9
- Fatigue and Sleep Deprivation 2
- Identification Errors 5
- Medical Complications 17
- Medication Errors/Preventable Adverse Drug Events 15
- Nonsurgical Procedural Complications 2
- Overtreatment 1
- Psychological and Social Complications 8
- Second victims 1
- Surgical Complications 19
- Allied Health Services 2
- Internal Medicine 35
- Pediatrics 8
- Nursing 12
- Pharmacy 10
- Family Members and Caregivers 1
- Health Care Executives and Administrators 107
Health Care Providers
- Nurses 17
- Physicians 30
- Non-Health Care Professionals 49
- Patients 15
- Africa 1
- China 1
- Australia and New Zealand 2
- Europe 18
- Canada 8
Search results for "Benchmarking"
- Health Care Providers
Tools/Toolkit > Toolkit
Horsham, PA: Institute for Safe Medication Practices; 2018.
Standardized practices have not been uniformly adopted to support safe IV medication therapy. This risk assessment tool will help organizations proactively identify process weaknesses that could contribute to patient harm. Users of the guide can also contribute to a national effort to collect data on current IV push practices. The data collection process is now closed.
Journal Article > Study
Pediatric airway management and prehospital patient safety: results of a national Delphi survey by the Children's Safety Initiative-Emergency Medical Services for Children.
Hansen M, Meckler G, O'Brien K, et al. Pediatr Emerg Care. 2016;32:603-607.
Appropriate airway management is a key component of resuscitation in the prehospital setting. This study surveyed prehospital professionals to understand elements of prehospital pediatric airway management that may contribute to patient safety events. Investigators found that insufficient experience with pediatric airway management and difficulty deciding when an advanced airway should be performed were viewed as highly likely to lead to safety events.
National Quality Partners. Washington, DC: National Quality Forum; 2016.
Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.
Journal Article > Study
Rinke ML, Singh H, Ruberman S, et al. Diagnosis. 2016;3:65-69.
Cambridge, MA: CRICO Strategies; 2016.
Communication failures are known to contribute to medical errors. Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores selected specialties where such failures occur and discusses opportunities to improve information sharing among health care providers.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2015. AHRQ Publication No. 15-0041-EF.
This survey expands AHRQ's patient safety culture work to the community pharmacy setting. Approximately 1600 pharmacy staff from 255 community pharmacies voluntarily completed the survey between 2013 and 2014. The database is meant to allow for comparison and benchmarking of safety cultures across pharmacies. However, the current response rate represents less than 1% of total community pharmacies in the United States, and more than half of respondents were chain drugstores or integrated health systems. Most community pharmacies scored well for patient counseling and communication openness, while staffing, work pressure, and pace represented the biggest areas for potential improvement. A prior AHRQ WebM&M interview with J. Bryan Sexton explored the relationship between culture and patient safety.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic 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.
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
Oakbrook Terrace, IL: The Joint Commission; September 2011.
This report emphasizes performance on Hospitals in the United States have made significant improvements in quality of care over the past several years, according to the sixth annual Joint Commission report. This report emphasizes performance on accountability measures—quality metrics that are closely tied to patient outcomes—and cites exemplar hospitals across the country that have demonstrated outstanding performance on these metrics for patients undergoing surgery, and for patients hospitalized with myocardial infarctions, pneumonia, and asthma (in children). Beginning in 2012, The Joint Commission began to integrate performance expectations on accountability measures into their annual accreditation surveys, meaning that for the first time, hospitals must demonstrate high-quality performance in order to retain accreditation.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0030.
The fifth annual edition of the AHRQ Hospital Survey on Patient Safety Culture comparative database presents benchmarking data for safety culture from more than 1000 hospitals nationwide, including trending data on changes in safety culture perception over time for more than 500 hospitals. The full report contains detailed comparative data for various hospital characteristics (type and size) and respondent characteristics (work areas, staff positions, and direct patient contact). Overall perception of safety culture improved compared with prior reports, and respondents specifically noted improvements in teamwork and management support of safety. However, persistent concerns were voiced about the safety of handoffs, and most respondents did not voluntarily report safety incidents.
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
This white paper identifies drivers of patient-centered care, and provides tools to help organizations improve the patient and family experience.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.
Cambridge, MA: CRICO/RMF Strategies; 2010.
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of surgical care.
Journal Article > Study
Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353.
Health care–associated infections are common and the subject of wide-scale prevention programs, despite concerns about their use as a quality metric. This study used a national database to examine the clinical and economic costs attributed to the development of health care–associated sepsis and pneumonia. Analyzing nearly 600,000 cases, investigators found 2.3 million hospitalization days, $8.1 billion in in-hospital costs, and 48,000 preventable deaths attributed to health care–associated sepsis and pneumonia. They also reported at least 40% higher length of stay and costs in patients with these complications who underwent invasive procedures compared to those who did not. Despite limitations in utilizing administrative data to draw clinical details, the findings are notable. A related commentary [see link below] discusses reducing preventable harm in the context of this study's findings, calling for greater investments in the science of health care quality and safety.
Journal Article > Study
Kazandjian VA, Ogunbo S, Wicker KG, Vaida AJ, Pipesh F. Qual Saf Health Care. 2009;18:331-335.
Use of the Institute for Safe Medication Practices Self-Assessment for Hospitals initiative resulted in improved medication safety in Maryland hospitals.
Ottawa, ON, Canada: Canadian Institute for Health Information; 2007. ISBN: 9781554651849.
This report describes a new metric used to analyze mortality rates in Canadian health care and also includes region-specific data.