Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 41
- Culture of Safety 40
- Education and Training 39
- Error Reporting and Analysis 73
- Human Factors Engineering 24
- Legal and Policy Approaches 43
- Logistical Approaches 5
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Quality Improvement Strategies
- Benchmarking 30
- Specialization of Care 2
- Teamwork 3
- Technologic Approaches 23
Safety Target
- Device-related Complications 18
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 7
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Medical Complications
41
- Delirium 1
- Medication Safety 49
- MRI safety 1
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 4
- Surgical Complications 18
Clinical Area
- Medicine 139
- Nursing 4
- Pharmacy 19
Target Audience
Search results for "Quality Improvement Strategies"
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- Quality Improvement Strategies
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Book/Report
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
Web Resource > Multi-use Website
Improving Diagnostic Accuracy Project 2016–2017.
Washington, DC: National Quality Forum; October 2016.
The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This website provides the information about a project that has convened an expert panel to identify and develop new measures to help address weaknesses in testing and tracking diagnostic accuracy. The program is currently accepting comments regarding the program framework. The submission deadline is July 12, 2017.
Book/Report
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Audiovisual > Audiovisual Presentation
The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety.
Rockville, MD: Agency for Healthcare Research and Quality; July 2016.
This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-9 to ICD-10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.
Book/Report
Resident Safety Practices in Nursing Home Settings.
Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-EHC022-EF.
Efforts to maintain patient autonomy can detract from ensuring residents' safety in nursing homes. Common safety issues in nursing homes are medication errors, falls, and inappropriate use of restraints. This technical brief discusses gaps in the research base that hinder understanding of the safety hazards in the residential care environment.
Newsletter/Journal
Innovations to improve patient safety.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
Web Resource > Government Resource
NHS Improvement.
National Health Service England.
The National Health Service (NHS) has been a global leader in patient safety improvement since the publication of An Organization With a Memory in 2000. This government resource combines several NHS initiatives—such as the National Reporting and Learning System and the Advancing Change Team—to oversee and provide support for clinicians.
Tools/Toolkit > Fact Sheet/FAQs
National Healthcare Quality and Disparities Report: Chartbook on Patient Safety.
Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0015-2-EF.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements in areas of focus such as hospital-acquired infections. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
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.
- Classic
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.
Audiovisual > Audiovisual Presentation
Eliminating Harm, Improving Patient Care: A Trustee Guide.
Chicago. IL: Health Research and Education Trust; August 2015.
Leadership commitment to improvement efforts is key to sustain patient safety initiatives. This toolkit consists of a workbook and video series to help leadership translate their efforts from the board room to the frontline to reduce medical errors in their hospitals.
Web Resource > Multi-use Website
Safer Clinical Systems.
London, UK: Health Foundation.
This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety improvement tactics from high-risk industries to care services. The program engages teams to identify problems in care delivery, develop innovations, and then test and evaluate the new approaches. The site provides access to project reports, overall guidance, and analysis of what was learned.
Tools/Toolkit > Multi-use Website
ANA CAUTI Prevention Tool.
Silver Spring, MD: American Nurses Association; 2015.
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, focuses on promoting nursing behaviors to prevent CAUTIs including decreasing catheter use and improving catheter maintenance.
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.
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.
- Classic
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.
Book/Report
National Action Plan for Adverse Drug Event Prevention.
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
This national action plan aims to align the efforts of multiple federal programs committed to reducing patient harms related to adverse drug events. The three initial high-priority targets of the action plan are anticoagulants, diabetes agents, and opioids. These medication classes were chosen due to their common usage and their very high potential to cause clinically significant, preventable, and measurable adverse events. The action plan outlines a four-pronged approach: surveillance, prevention, incentives and oversight, and research. The full report delves into detailed tactics for each of these areas, as well as for the three drug classes. Focusing on specific high-risk drug classes, rather than pursuing the commonly advocated approach of universal drug safety, was also recommended by a recent systematic review of medication errors.
Grant
Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. August 6, 2014. PA-14-311; PA-14-312; PA-14-313.
Book/Report
Advances in the Prevention and Control of HAIs.
- Classic
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.
Journal Article > Government Resource
Vital signs: improving antibiotic use among hospitalized patients.
- Classic
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.
Web Resource > Government Resource
National Patient Safety Alerting System.
National Health Service England.
In response to the Francis report, this three-stage reporting system was launched to help National Health Service organizations learn from incidents and incorporate changes to reduce similar risks. The first stage alerts organizations of a new patient safety hazard, the second distributes practices or resources to address the issue, and the third disseminates a checklist to ensure safety strategies have been implemented. In April 2016 the alerts program was integrated into the new NHS Improvement initiative.