Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 16
- Culture of Safety 12
- Education and Training 46
- Error Reporting and Analysis 89
- Human Factors Engineering 16
- Legal and Policy Approaches 30
- Logistical Approaches 4
- Quality Improvement Strategies 39
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 26
Safety Target
- Device-related Complications 10
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 10
- Drug shortages 2
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 36
- Medication Safety 43
- MRI safety 1
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 6
- Surgical Complications 16
- Transfusion Complications 1
Setting of Care
Clinical Area
- Allied Health Services 1
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Medicine
162
- Primary Care 11
- Surgery 11
- Nursing 5
- Pharmacy 12
Target Audience
Error Types
- Active Errors 5
- Epidemiology of Errors and Adverse Events
- Latent Errors 1
- Near Miss 1
Search results for "Epidemiology of Errors and Adverse Events"
- Web Resource
- Epidemiology of Errors and Adverse Events
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Audiovisual
Making health care safer: protect patients from antibiotic resistance.
CDC Vital Signs. March 3, 2016.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
Book/Report
Saving Lives and Saving Money: Hospital-Acquired Conditions Update.
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Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
Book/Report
Indiana Medical Error Reporting System: Final Report for 2014.
Whitson T, Garten B, Ordway GV. Indianapolis, IN: Indiana State Department of Health; 2015.
This annual report provides information on never events reported to the Indiana Medical Error Reporting System. The most common problems in the 114 incidents reported in 2014 were advanced pressure ulcers, retained foreign objects, and wrong-site surgery. Past reports are also available.
Book/Report
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
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Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Grant > Government Resource
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services. August 25, 2015. Program Announcement No. PA-15-339.
This AHRQ funding opportunity will support research regarding effective identification and tracking of adverse events in ambulatory and long-term care settings, particularly projects focused on understanding disparities in patient safety.
Web Resource > Multi-use Website
Resilient Health Care Net.
Region of Southern Denmark, the Centre for Quality Improvement, Faculty of Health Sciences, Faculty of Social Sciences at the University of Southern Denmark; Middelfart, Denmark.
Resilience engineering provides a structure to enable teams and organizations to respond to emergent problems. This initiative supports networking and research related to this approach to ensure the core elements are successfully applied to health care.
Book/Report
National and State Healthcare-Associated Infections Progress Report.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; January 2015.
This annual analysis explores rates of health care–associated infections reported in the United States. Data from 2013 revealed significant reductions central line–associated bloodstream infections and surgical site infections, while rates of catheter-associated urinary tract infections increased, raising awareness of the need for enhanced prevention efforts nationwide.
Book/Report
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
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Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Web Resource > Government Resource
Serious Reportable Events.
Nova Scotia Department of Health and Wellness.
Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to information about serious adverse events reported to the Department of Health and Wellness in Nova Scotia related to surgical procedures, product or device use, patient harm, care management, and hospital environment.
Audiovisual
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
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Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014). (Testimony of John James, PhD; Ashish Jha, MD, MPH; Tejal Gandhi, MD, MPH; Peter Pronovost, MD, PhD; Joanne Disch, PhD, RN; Lisa McGiffert.)
A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.
Newspaper/Magazine Article
24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Effective monitoring can enable early detection of deteriorating patients while reducing nuisance alarms. Relating how one hospital implemented round-the-clock monitoring and adjusted alarm thresholds, this article reports results of the program such as fewer patient transfers to the intensive care unit and no subsequent adverse events.
Newspaper/Magazine Article
Medication administration errors in hospitals—challenges and recommendations for their measurement.
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.
Journal Article > Government Resource
Vital signs: improving antibiotic use among hospitalized patients.
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Fridkin S, Baggs J, Fagan R, et al; National Center for Emerging and Zoonotic Infectious Diseases, CDC. MMWR Morb Mortal Wkly Rep. 2014;63:194-200.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Book/Report
Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.
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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.
Book/Report
Maryland Hospital Patient Safety Program Annual Report: Fiscal Year 2014.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; March 2015.
This annual report summarizes never events in Maryland hospitals over the previous year. In 2014, reported hospital-acquired infections and readmissions decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including standardizing processes and engaging hospital and departmental leaders in safety initiatives.
Web Resource > Government Resource
Healthcare–Associated Infections (HAI).
Atlanta, GA: Centers for Disease Control and Prevention.
This Web site provides information about government initiatives to research and prevent health care–associated infections.
Audiovisual
2014 Serious Reportable Events in Massachusetts.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; June 2015.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest increase in serious reportable events recorded, from 753 the previous year to 821. This presentation also includes events from ambulatory surgery centers.
Web Resource > Multi-use Website
Anesthesia Awareness Registry.
American Society of Anesthesiologists Committee on Professional Liability.
This Web site supports a project on understanding patient awareness during surgery and provides materials to consumers and clinicians about the problem.
Web Resource > Government Resource
National Comparative Audit of Blood Transfusion.
National Blood Service Hospitals.
This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.
Web Resource > Multi-use Website
AHRQ Safety Program for Improving Surgical Care and Recovery.
Rockville, MD: Agency for Healthcare Research and Quality.
Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-based Safety Program to help hospitals integrate best practices into all stages of surgery to ensure safe recovery. Targeted areas of improvement include safety culture development, teamwork skills, and partnering with patients.