Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 14
- Culture of Safety 17
- Education and Training 20
- Error Reporting and Analysis 39
- Human Factors Engineering 9
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Legal and Policy Approaches
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Incentives
34
- Financial 15
- Regulation 21
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Incentives
34
- Logistical Approaches 4
- Quality Improvement Strategies 43
- Specialization of Care 2
- Teamwork 5
- Technologic Approaches 15
Safety Target
- Device-related Complications 3
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 9
- Drug shortages 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 4
- Medical Complications 19
- Medication Safety 26
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 7
Clinical Area
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Medicine
56
- Surgery 2
- Pharmacy 11
Target Audience
Search results for "Legal and Policy Approaches"
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Newsletter/Journal
Making care safer.
Agency for Healthcare Research and Quality. Priorities in Focus. March 2016.
The National Quality Strategy is part of AHRQ's ongoing efforts to enhance patient safety. This brief summarizes the results of the Partnership for Patients program and other initiatives working toward achieving the goals of the National Quality Strategy, including reducing hospital-acquired conditions, preventable readmissions, and patient harm.
Book/Report
Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Legislation/Regulation > Government Resource
Medicare and Medicaid programs; reform of requirements for long-term care facilities; proposed rule.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Centers for Medicare & Medicaid Services. July 16, 2015;80:42167-42269.
Poor safety culture and lack of available resources to provide high-quality care can hinder safety in long-term care facilities. This set of regulations will revise requirements for long-term care facilities in areas such as clinical practice standards, service delivery, patient-centeredness, and infection control. The deadline for officially submitting comments on the proposed rule was September 14, 2015.
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.
Web Resource > Multi-use Website
Patient Safety Measures.
Washington, DC: National Quality Forum.
This Web site tracks the progress of the development and review of measures to enhance reporting and accountability of health care organizations in addressing risks to patient safety.
Book/Report
Patient Safety Act.
Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10-281.
This report describes progress in implementing the Patient Safety and Quality Improvement Act. The document details development of Patient Safety Organizations and the plans to establish a network of patient safety databases, which must be completed before evaluating the law's effectiveness.
Book/Report
Advances in Patient Safety: New Directions and Alternative Approaches.
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Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Web Resource > Government Resource
Patient Safety Organization (PSO) Program.
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Agency for Healthcare Research and Quality.
In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient care," the Agency for Healthcare Research and Quality (AHRQ) is spearheading the certification of Patient Safety Organizations (PSOs)—public or private organizations with expertise in the analysis of patient safety and hazards in health care. This Web site provides information on the rules governing PSOs and the requirements for an organization to be listed as a PSO. Development of PSOs was authorized by the 2005 Patient Safety and Quality Improvement Act.
Web Resource > Multi-use Website
Lucian Leape Institute at the National Patient Safety Foundation.
268 Summer Street, 6th Floor, Boston, MA 02210.
This organization prepares recommendations and reports, provides opportunities for collaboration, and outlines the direction of strategic efforts in patient safety.
Legislation/Regulation > Congressional Testimony
Medical Liability: New Ideals for Making the System Work Better for Patients.
Hearings before the Senate Committee on Health, Education, Labor, and Pensions, 109th Cong, 2nd Sess (June 22, 2006).
This congressional committee hearing explored possible changes to the U.S. medical liability system to more effectively help patients, families, and physicians who have been affected by failures in medical care.
Book/Report
Advances in Patient Safety: From Research to Implementation.
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Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Web Resource > Multi-use Website
University of Michigan's Patient Safety Enhancement Program (PSEP).
University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109. Phone: (734) 936-4000.
The University of Michigan's Patient Safety Enhancement Program (PSEP) aims to improve the quality of patient care by conducting research that focuses on methods to prevent adverse patient outcomes.
Legislation/Regulation
Summary of Proposed Changes to ACGME Common Program Requirements Section VI.
Accreditation Council for Graduate Medical Education.
Implementation of resident duty hours, meant to address fatigue in health care, has long been a subject of patient safety discussions. This website provides a summary of proposed changes to the current ACGME residency Common Program Requirements that shape working hours, offers rationale for the revisions.
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.
Press Release/Announcement
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.
National attention has focused on efforts to address adverse drug events. This call for comments seeks insights regarding revisions to a 2014 action plan that highlighted how to reduce adverse drug events associated with anticoagulants, diabetes agents, and opioids. These proposed updates involve measures to apply in both the inpatient and outpatient environments to track adverse drug events. The opportunity to submit written comments is now closed.
Legislation/Regulation > Government Resource
ONC Health IT Certification Program: Enhanced Oversight and Accountability.
Federal Register. Washington, DC: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2016;81:72404-72471.
Requirements are needed to manage risks associated with health information technology systems. This final rule provides a framework for government review of technologies certified by the ONC Health IT Certification Program. The rule also covers certification guidance for testing laboratories. The regulations go into effect December 19, 2016.
Grant > Government Resource
Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.
Rockville, MD: Agency for Healthcare Research and Quality; October 13, 2016. PA-17-007 and PA-17-008.
Health care–associated infections occur across various health care settings. AHRQ seeks to support large research (R01) and dissemination (R18) projects working to develop strategies and approaches for preventing and reducing health care–associated infections. Applications will be accepted on a standard submission schedule through January 26, 2021 for the R18 funding and March 6, 2021 for the R01 funding.
Grant > Fact Sheet/FAQs
Partnership for Patients and the Hospital Improvement Innovation Networks: Continuing Forward Momentum on Reducing Patient Harm.
Fact Sheets. Baltimore, MD: Centers for Medicare & Medicaid Services; September 29, 2016.
The Partnership for Patients program is credited with supporting harm reduction in hospitalized patients across the United States through the Hospital Engagement Networks (HEN). This fact sheet summarizes the next round of funding that will build on HEN accomplishments to support innovation with a goal of reducing hospital-acquired conditions and preventable readmissions by 2019.
Grant > Government Resource
Advances in Patient Safety through Simulation Research (R18).
Rockville, MD: Agency for Healthcare Research and Quality. PA-16-420.
This grant will support funding for the development, testing, and evaluation of simulation as a mechanism to identify opportunities for improvements in safety. The submission process opens November 25, 2016 and is scheduled to run until January 26, 2022.
Journal Article > Government Resource
Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015.
García MC, Dodek AB, Kowalski T, et al. MMWR Morb Mortal Wkly Rep. 2016;65:1125-1131.
Adverse drug events related to opioid medications are a significant patient safety concern. This analysis of insurer claims data demonstrated that changing opioid prescribing requirements, including implementing patient–provider agreements, requiring prior authorization, and enforcing quantity limits, led to a decline in opioid prescribing. The authors recommend that insurers implement policies from the Centers for Disease Control and Prevention opioid guidelines to improve safety.