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Approach to Improving Safety
Safety Target
- Device-related Complications 8
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 2
- Medical Complications 10
- Medication Safety 17
- MRI safety 1
- Surgical Complications 5
Target Audience
Search results for "Practice Guidelines"
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- Practice Guidelines
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Book/Report
Patient and Family Engagement in Primary Care: Case Studies.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.
Book/Report
National Safety Standards for Invasive Procedures (NatSSIPs).
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.
Book/Report
Guide to Patient and Family Engagement: Environmental Scan Report.
Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0042-EF.
This report describes the state of currently available resources to promote patient and family engagement in their health care.
Audiovisual
Making health care safer: stopping C. difficile infections.
CDC Vital Signs. March 2012:1-4.
This newsletter article and accompanying set of infographics describes strategies to help patients and health care providers prevent health care–associated infections.
Book/Report
Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.
Atlanta, GA: Centers for Disease Control and Prevention; 2011.
This report suggests strategies to prevent infections in the outpatient setting and provides links to more detailed infection prevention information.
Web Resource > Multi-use Website
Association for Professionals in Infection Control and Epidemiology.
1275 K St, NW, Suite 1000, Washington, DC 20005.
This Web site offers news articles, event listings, and information on minimizing health care-associated infections for both professional and lay audiences.
Tools/Toolkit > Fact Sheet/FAQs
Thirty Safe Practices for Better Health Care.
National Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. AHRQ Publication No. 04-P025.
This fact sheet presents 30 safe practices that can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all applicable health care settings to reduce the risk of harm to patients. The practices are derived from a 2003 consensus report developed by the National Quality Forum.
Book/Report
Global Guidelines on the Prevention of Surgical Site Infection.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.
Web Resource > Multi-use Website
Indiana Patient Safety Center.
Indiana Hospital Association.
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.
Web Resource > Multi-use Website
Standardize 4 Safety.
American Society of Health-System Pharmacists.
Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.
Book/Report
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.
Tools/Toolkit > Fact Sheet/FAQs
Explicit and Standardized Prescription Medicine Instructions.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
Standardization has been embraced as a strategy to improve health literacy and to reduce patient misunderstanding of medication instructions. This tool provides standard language that clarifies directions for patients regarding when they should take their medications.
Book/Report
An avoidable death of a three-year-old child from sepsis.
London, UK: Parliamentary and Health Service Ombudsman; June 24, 2014.
This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.
Book/Report
Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.
NHS England Never Events Taskforce. London, UK: NHS England; February 27, 2014.
Examining risks in surgical care such as deviation in practice, this report outlines strategies to improve outcomes, including better adoption of care standards, determining organizational safety policies, and multidisciplinary training initiatives.
Web Resource > Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Children are often prescribed oral liquid medications due to difficulty swallowing tablets or capsules. This Web site provides resources for an initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead to medication errors.
Book/Report
Strategic Plan for Preventing and Mitigating Drug Shortages.
Silver Spring, MD: Food and Drug Administration; October 2013.
This report outlines the FDA's plans to address drug shortages, including streamlining tracking processes and developing early warning signals to identify potential shortages.
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.
Journal Article > Commentary
CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2013;62:423-425.
This commentary examines unsafe injection practices in the United States and reviews a four-element approach to reduce risks.
Book/Report
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
- Classic
Shekelle PG, Wachter RM, Pronovost PJ, eds. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 13-E001-EF.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Book/Report
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
This guide and corresponding TeamStepps module address how to improve care for patients with limited English proficiency.