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- Communication Improvement 3
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 3
- Device-related Complications 2
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events
- Surgical Complications 2
Search results for "Hospital Medicine"
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
This report summarizes findings from interviews with AHRQ-funded grantees who have implemented computerized provider order entry systems.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Tools/Toolkit > Fact Sheet/FAQs
Decisionmaker Brief. AHRQ Publication No: 08-0085, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.
This document summarizes the experience of numerous AHRQ-funded programs in implementing bar-coded medication administration.