Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 32
- Culture of Safety 40
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Education and Training
37
- Students 2
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Error Reporting and Analysis
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Error Reporting
124
- Never Events 12
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Error Reporting
124
- Human Factors Engineering 16
- Legal and Policy Approaches 39
- Logistical Approaches 4
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Quality Improvement Strategies
73
- Benchmarking 10
- Specialization of Care 1
- Teamwork 9
- Technologic Approaches 24
Safety Target
- Device-related Complications 13
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 12
- Drug shortages 1
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 7
- Medical Complications 32
- Medication Safety 57
- MRI safety 2
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 10
- Surgical Complications 21
Clinical Area
- Allied Health Services 1
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Medicine
137
- Surgery 13
- Nursing 5
- Pharmacy 11
Target Audience
Search results for "Error Reporting and Analysis"
- Web Resource
- Error Reporting and Analysis
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Newsletter/Journal
PSO Program Briefs.
Agency for Healthcare Research and Quality.
Patient safety organizations (PSO) augment learning by sharing data from voluntary reporting and informing safety interventions. This series of articles discusses PSO-related programs that resulted in improvements, such as readmission reduction.
Book/Report
Final Report of the Commission on Care.
Washington, DC: Commission on Care; June 2016.
The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future state of the Veterans Health Administration, this report determined that care quality often meets or exceeds expectations but that quality varies from location to location. The authors outline recommendations for system improvements to ensure the safety of care delivery.
Tools/Toolkit > Government Resource
Ambulatory Surgery Center Survey on Patient Safety Culture.
Rockville, MD: Agency for Healthcare Research and Quality; April 2016.
Ambulatory surgery centers are increasingly being used to provide surgical care. This survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide.
Web Resource > Government Resource
Overall Hospital Quality Star Ratings Overview.
QualityNet. Centers for Medicare & Medicaid Services.
Hospital rating programs have received significant public attention, but concerns have been raised regarding their usefulness. This website provides resources to augment usability of this data including reports describing the methodology used by the Centers for Medicare and Medicaid Services to generate the information provided on the Hospital Compare website.
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.
Book/Report
National Reporting and Learning System Research and Development.
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
Incident reporting has achieved varying levels of success in encouraging transparency and facilitating system learning. This publication discusses reporting initiatives in the National Health Service and focuses on the importance of considering system purpose, user experience, data integrity, and feedback process to enhance reporting systems.
Book/Report
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.
Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-308.
Despite support for evidence-based medicine as a strategy to improve safety and quality, reliable use of best practices is lacking. Analyzing how six hospitals tried to implement evidence-based safety practices, this report identified in-house incident data use, practice selection, and implementation consistency as challenges to sustainable use of best practices.
Book/Report
Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies.
Mannion R, Freeman T, Millar R, Davies H. Health Serv Deliv Res. 2016;4:1-165.
This mixed-methods analysis of four trusts in the National Health Service (NHS) found that evident board commitment and behavior supporting safety encourages staff to raise concerns that can lead to improvements. The authors suggest their results should help to inform hospital board training and recruitment efforts across the NHS.
Book/Report
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
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.
Book/Report
Learning Not Blaming.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Web Resource > Multi-use Website
Radiation Oncology Incident Learning System.
American Society for Radiation Oncology and American Association of Physicists in Medicine.
Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.
Book/Report
Patient Safety 2015: Final Technical Report.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
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.
Book/Report
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
- Classic
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
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.
Book/Report
The Report of the Morecambe Bay Investigation.
Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
Sharing information about large-scale investigations into failures can provide insights on factors that contribute to adverse clinical incidents. This report discusses an analysis of care delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems that were perpetuated due to failure to look into the initial event.
Meeting/Conference > Government Resource
AHRQ 2010 Annual Conference.
Rockville, MD: Agency for Healthcare Research and Quality; November 2010.
This Web site provides videos of plenary addresses from the 2010 AHRQ Annual Conference, including presentations by Carolyn Clancy, MD, and Atul Gawande, MD.
Press Release/Announcement
Common formats for patient safety data collection and event reporting.
Federal Register. October 22, 2010;75:65359-65360.
This announcement discusses the Patient Safety Act, describes the role of Common Formats in collecting adverse event data through Patient Safety Organizations, and calls for feedback from the field to guide modifications.
Web Resource > Multi-use Website
Childrens' Hospitals' Solutions for Patient Safety.
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
This Web site provides resources related to a collaborative effort involving more than 80 hospitals with a goal of reducing health care–associated conditions, readmissions, and serious safety events.