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Book/Report
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Evidence Report/Technology Assessment: Number 74. Rockville, MD: Agency for Healthcare Research and Quality; March 2003. AHRQ Publication No. 03-E024.
This report summarizes existing scientific evidence on the role health care working conditions play in patient safety efforts.
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.
Audiovisual
Training Program for Nurses on Shift Work and Long Work Hours.
Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; May 2015. DHHS NIOSH Publication No. 2015-115.
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
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.
Legislation/Regulation > Congressional Testimony
Examining the Increase in Drug Shortages.
Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).
This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.
Book/Report
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report.
Carayon P, Karsh B-T, Cartmill RS, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2010. AHRQ Publication No. 10-0098-EF.
The report summarizes evidence related to the impact of health information technology on workflow in outpatient settings.
Newspaper/Magazine Article
Diagnostic error in acute care.
PA-PSRS Patient Saf Advis. 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Book/Report
Characteristics of Weekday and Weekend Hospital Admissions, 2007.
Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.
Using data from the Healthcare Cost and Utilization Project, this report analyzed characteristics of weekend hospital stays and found that patients experienced delays in receiving care compared with patients admitted during the week.
Tools/Toolkit > Fact Sheet/FAQs
10 Patient Safety Tips for Hospitals.
- Classic
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Web Resource > Multi-use Website
Nursing Care Quality at NQF.
National Quality Forum.
This Web site provides information on National Quality Forum activities in understanding nurses' impact on patient safety and quality.
Book/Report
Patient Safety.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Book/Report
Safe Practices for Better Healthcare–2009 Update.
National Quality Forum. Washington, DC: National Quality Forum; 2009.
The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations to improve the quality and safety of patient care. The practices are organized into seven content areas: establishing leadership structures and systems, improving safety culture, honoring patient's wishes for informed consent and error disclosure, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. Since the last update in 2006, seven new practices have been added and others retired. The practices are defined so that organizations can measure the relationship between implementation of the practices and patient safety outcomes.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Book/Report
Correlates of Medication Error in Hospitals.
Wilkins K, Shields M. Ottawa, Canada: Statistics Canada; May 2008. Catalogue no. 82-003-X Health Reports.
This report describes results of a large survey of Canadian nurses and identifies work-related factors that contribute to medication errors.
Tools/Toolkit > Multi-use Website
Door-to-Doc Patient Safety Toolkit.
Phoenix, AZ: Banner Health; 2007.
This AHRQ-funded toolkit provides templates and other documentation support to help hospitals implement an initiative to improve patient flow processes by reducing the time emergency department patients wait to be seen and admitted. The model is also designed to gain front-line practitioner acceptance of these changes and to improve both efficiency and patient safety.
Audiovisual
Healthcare 411: Consumer insider—handwashing.
Rockville, MD: Agency for Healthcare Research and Quality. June 20, 2007.
This podcast discusses the importance of handwashing to reduce infections in hospitals as well as how consumers can help improve clinician compliance.
Newspaper/Magazine Article
Five hospitals release data on inspections.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Book/Report
Keeping Patients Safe: Transforming the Work Environment of Nurses.
- Classic
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.