Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Hospitals"

1 - 20 of 1765 results
Download Selected Citations

Show: 20 | 50 | 100

Newspaper/Magazine Article

How your hospital can make you sick.

Consumer Reports. July 29, 2015.

This news article reports on health care–associated infections, particularly Clostridium difficile and methicillin-resistant Staphylococcus aureus, discusses ways hospitals and patients can help prevent them, and emphasizes the need to advocate for reduced antibiotic use and improved cleanliness.

Book/Report

Guidelines for Adult IV Push Medications.

Horsham, PA: The Institute for Safe Medication Practices; July 2015.

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

Journal Article > Commentary

The problem with checklists.

Catchpole K, Russ S. BMJ Qual Saf. 2015;24:545-549.

Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlighting the complexities around designing and implementing checklists to augment health care safety, this commentary relates the differences between medical and aviation checklists to underscore the need to consider sociocultural elements to ensure the success of this safety intervention.

Journal Article > Study

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence.

Millar R, Freeman T, Mannion R. BMC Health Serv Res. 2015;15:196.

This qualitative study examined mechanisms by which hospital boards could provide more effective oversight of quality and safety activities. Trust among organizational leadership and prioritization of data analysis emerged as important methods by which boards could help improve safety.

Journal Article > Commentary

Concepts for the development of a customizable checklist for use by patients.

Fernando RJ, Shapiro FE, Rosenberg NM, Bader AM, Urman RD. J Patient Saf. 2015 Jun 10; [Epub ahead of print].

Checklists have been highlighted as useful tools for nurses and physicians to improve communication and reduce care omissions. This commentary describes the development of a customizable checklist template designed to enable patients to engage in their care and safety.

Journal Article > Commentary

A scholarly pathway in quality improvement and patient safety.

Ferguson CC, Lamb G. Acad Med. 2015;90:1358–1362.

There is a recognized need for patient safety content in medical school curricula. This commentary describes the development, implementation, and evaluation of a program that integrated quality and safety improvement concepts into an existing 3-year curriculum. A patient safety expert worked with faculty to recommend the content and goals of the pathway. Students reported positive reactions to the program.

Journal Article > Study

Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge.

Mussman GM, Vossmeyer MT, Brady PW, Warrick DM, Simmons JM, White CM. J Hosp Med. 2015;10:574-580.

Every day the care of hospital patients is handed off from clinician to clinician, creating serious risks for patient safety. A comprehensive quality improvement program that standardized communication processes and introduced basic electronic health record messaging enhanced the rate of postdischarge verbal handoffs to primary care providers.

Book/Report

The Patient Survival Handbook.

Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.

Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.

Journal Article > Commentary

Hospital ratings: a guide for the perplexed.

Zuger A. JAMA. 2015;313:1911-1912.

Concerns have been raised about the variability of measures used to rate safety and quality in hospitals. Spotlighting the growing focus on publicly available quality data, this commentary provides information about the science of quality measurement, including the differences between rating systems and the strengths and weaknesses of numerical data versus survey responses.

Journal Article > Commentary

Improving medication administration safety in a community hospital setting using Lean methodology.

Critchley S. J Nurs Care Qual. 2015;30:345-351.

The Toyota production system and Lean methodologies have been used to improve quality and drive process improvement in health care. This commentary discusses how one hospital applied Lean methodology in an interdisciplinary effort to enhance medication administration safety.

Web Resource > Multi-use Website

National Coalition for Alarm Management Safety.

Healthcare Technology Safety Institute and Association for the Advancement of Medical Instrumentation.

Alarm fatigue has been recognized as a contributor to serious errors in hospitals. This Web site provides a way for hospitals, industry representatives, regulators, and professional societies to compile resources and discuss strategies to reduce unnecessary alarms.

Journal Article > Commentary

Patient safety: let's measure what matters.

Thomas EJ, Classen DC. Ann Intern Med. 2014;160:642-643.

This commentary discusses challenges related to the use of numerous measures for adverse events in hospitals in the United States. The authors explain how continually adding mandated safety measures can detract from safety improvement by overwhelming hospital workers with the burden of tracking and failing to record new types of errors.

Journal Article > Review

Pediatric obesity and safety in inpatient settings: a systematic literature review.

Halvorson EE, Irby MB, Skelton JA. Clin Pediatr (Phila). 2014;53:975-987.

This systematic review sought to determine how obesity affects the risk of adverse events in hospitalized children. Investigators found evidence that pediatric patients with obesity experienced more adverse events in inpatient settings than those who are not obese. Elevated risks of medication errors, venous thromboembolism, surgical complications, and airway management were found in hospitalized children with obesity. Based on these findings, the authors conclude that increased hospital awareness and new safety strategies are needed to enhance safety for obese pediatric patients. A previous AHRQ WebM&M commentary describes unrecognized symptoms in an adolescent patient with obesity.

Journal Article > Study

Who do hospital physicians and nurses go to for advice about medications? A social network analysis and examination of prescribing error rates.

Creswick N, Westbrook JI. J Patient Saf. 2015;11:152-159.

This analysis sought to characterize how physicians and nurses acquire information about medication prescribing. Physicians rarely elicited medication prescribing advice from individuals and more frequently referred to paper or computerized resources. A ward with a better information-sharing network had fewer medication errors, highlighting the value of interprofessional information-sharing as a critical component of safety culture.

Tools/Toolkit > Government Resource

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.

This toolkit offers information and resources to guide hospitals through process change to implement and sustain fall prevention efforts.

Web Resource > Multi-use Website

North Carolina Center for Hospital Quality and Patient Safety.

2400 Weston Parkway, Cary, NC 27514.

The center was created by the North Carolina Hospital Association to provide education and other resources that support patient safety efforts in North Carolina hospitals.

Tools/Toolkit > Fact Sheet/FAQs

10 Patient Safety Tips for Hospitals.

  • Classic

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.

Book/Report

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

This guide contains comprehensive information about best practices and implementation tools to help health care facilities build a culture of patient-centered care.

Newspaper/Magazine Article

Why pay for mistakes?

Leape L. Boston Globe. August 23, 2007;Op-Ed section:9A.

Recently, CMS ruled that Medicare will no longer cover certain preventable errors. In this op-ed piece, the author discusses why this new rule will drive hospitals to implement safety measures.

Journal Article > Study

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.

This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.

Back to Top