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Web Resource > Government Resource
Partnership for Patients.
- Classic
Washington, DC: US Department of Health and Human Services.
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to decrease preventable harm in United States hospitals. Its emphasis on partnerships (between government, provider organizations, payers, and patients) echoes certain Institute for Healthcare Improvement (IHI) campaigns, developed by Medicare director Dr. Donald Berwick while he led IHI. The Partnership focuses on skill building, demonstration projects, and collaboratives. Through 2019, the Hospital Improvement and Innovation Networks will work to achieve a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions as a population-based measure from the 2014 baseline. In September 2015, the program awarded $110 million to 17 national, regional, or state hospital associations and health system organizations. CMS estimates that 2.1 million fewer patients were harmed and nearly $20 in health care costs were saved from 2010 to 2014. Medicare hopes these recent monetary awards will continue to drive this momentum on improving patient safety.
Special or Theme Issue
Medical Error Reporting.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 23, 2010.
This issue features successful patient safety innovations pertaining to disclosure, multidisciplinary patient safety conferences, and proactive reporting.
Tools/Toolkit > Government Resource
Guide for Developing a Community-Based Patient Safety Advisory Council.
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
Book/Report
Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment.
Hsu EB, Jenckes MW, Catlett CL, et al. Summary, Evidence Report/Technology Assessment: Number 95. Rockville, MD: Agency for Healthcare Research and Quality; April 2004. AHRQ Publication Number 04-E015-1.
This report focuses on the effectiveness of hospital disaster drills, computer simulations, and tabletop or similar exercises in training hospital staff to respond to a mass casualty incident (MCI).
Audiovisual > Audiovisual Presentation
Presenting TeamSTEPPS in the Perioperative Setting.
TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).
TeamSTEPPS is a process to enhance communication and teamwork in health care. This webinar will offer insights on implementing TeamSTEPPS in a large health system to improve perioperative practice. The session will highlight developing leadership as program champions, creating learning materials, and monitoring as tactics for sustaining improvements. This is part of a monthly series of educational modules on TeamSTEPPS.
Tools/Toolkit > Government Resource
Toolkit To Improve Safety in Ambulatory Surgery Centers.
Agency for Healthcare Research and Quality: Rockville, MD.
Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.
Book/Report
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
Tools/Toolkit > Multi-use Website
TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.
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Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.
Tools/Toolkit > Government Resource
CUSP Toolkit.
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Rockville, MD: Agency for Healthcare Research and Quality; June 2015.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Web Resource > Multi-use Website
STate Action on Avoidable Rehospitalizations.
Institute for Healthcare Improvement.
This Web site supports an initiative to reduce avoidable rehospitalizations by improving transitions in care and communication between multiple care sites.
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.
Grant > Government Resource
Understanding Clinical Information Needs and Health Care Decision Making Processes in the Context of Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality. Program Announcement No. PA-11-198.
This AHRQ funding program will support research in team decision making processes in health care.
Web Resource > Multi-use Website
Collaborating and Acting Responsibly to Ensure Safety (CARES) Alliance.
Covidien.
This collaborative venture seeks to improve opioid medication safety by providing information to patients, providers, and pharmacists.
Web Resource > Government Resource
Department of Defense (DoD) Patient Safety Program.
United States Department of Defense.
This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce medical error through leadership, transparency, teamwork, and communication.
Tools/Toolkit > Government Resource
Professional Conduct Toolkit.
Washington, DC: US Department of Defense, Patient Safety Program.
This toolkit provides a checklist, a planning guide, and other tools to help address disruptive staff behavior.
Book/Report
Advancing Patient Safety: A Decade of Evidence, Design, and Implementation.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Newspaper/Magazine Article
Beyond the count: preventing the retention of foreign objects.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
Tools/Toolkit > Course Material/Curriculum
Patient Safety Toolkits & E-learning Packages.
National Patient Safety Agency.
This Web site offers a collection of tools and educational materials to bolster patient safety training at the local level.
Tools/Toolkit > Government Resource
Seven steps to patient safety in general practice.
National Patient Safety Agency. London, England: NHS; 2009.
This guide is from a series of National Patient Safety Agency publications that encourage improvements in distinct areas of medical practice in the United Kingdom. This installment offers various exercises to develop safety strategies and tips for safe care in general practice.
Web Resource > Multi-use Website
The Safety Competencies Framework.
Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them.