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Approach to Improving Safety
- Communication Improvement 17
- Culture of Safety 9
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Education and Training
17
- Students 1
- Error Reporting and Analysis 24
- Human Factors Engineering 13
- Legal and Policy Approaches 15
- Logistical Approaches 2
- Quality Improvement Strategies 23
- Specialization of Care 3
- Teamwork 5
- Technologic Approaches
Safety Target
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 8
- Fatigue and Sleep Deprivation 2
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 5
- Medication Safety 32
- Psychological and Social Complications 2
- Surgical Complications 3
- Transfusion Complications 1
Clinical Area
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Search results for "Technologic Approaches"
- Web Resource
- Technologic Approaches
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Web Resource > Government Resource
Injury Prevention & Control: Opioid Overdose.
Centers for Disease Control and Prevention.
Concerns about patient harm from prescription opioid misuse are increasing in the United States. This website provides guidelines for use of opioid medications and information to raise awareness about the need to improve physicians' prescribing decisions and patients' medication use.
Press Release/Announcement
AHRQ announces interest in research on health IT safety.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.
This announcement highlights AHRQ funding opportunities to support continued research regarding the safe use and implementation of health information technology systems with a focus on usability, user interaction, human factors engineering, system monitoring, and performance.
Book/Report
Health IT Safety Center Roadmap.
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
The Institute of Medicine called for enhanced transparency in the reporting of health IT safety incidents to inform implementation and use of such technologies. This report reviews insights from a multidisciplinary task force that discussed how to design an entity focused on improving health IT–related safety that enables collaboration and learning.
Book/Report
Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign.
Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.
Web Resource > Government Resource
Patient Centered Medical Home Resource Center: Quality and Safety.
Rockville, MD: Agency for Healthcare Research and Quality.
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.
Book/Report
Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative.
Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF.
This report highlights findings from 24 AHRQ-funded projects investigating how health information technology can improve clinician decision making, care coordination, and clinical workflow to achieve better outcomes.
Web Resource > Government Resource
Health IT Hazard Manager.
Rockville, MD: Agency for Healthcare Research and Quality.
This Web site provides information associated with a software tool to identify and prevent hazards from health information technology use.
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.
Book/Report
Advances in Patient Safety: New Directions and Alternative Approaches.
- Classic
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.
Book/Report
Advances in Patient Safety: From Research to Implementation.
- Classic
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 > Database/Directory
National Quality Measures Clearinghouse (NQMC).
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2003.
This web-accessible database provides access to evidence-based quality measures and measure sets. The mission of the National Quality Measures Clearinghouse (NQMC) is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further their dissemination, implementation, and use in order to inform health care decisions.
Tools/Toolkit > Fact Sheet/FAQs
Reducing Errors in Health Care: Translating Research Into Practice.
Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Publication 00-PO58.
This fact sheet on medical errors provides information based on current research. Patients at risk, types of medical errors, and ways to improve and promote patient safety are discussed. References to programs and publications on medical errors and patient safety are provided.
Audiovisual > Audiovisual Presentation
A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation.
Agency for Healthcare Research and Quality. February 7, 2017.
Incomplete clinical notes create potential for treatment errors. This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation and highlight natural language processing technologies as a component of this strategy.
Book/Report
Examining the Copy and Paste Function in the Use of Electronic Health Records.
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.
Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.
Book/Report
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
Use of medication administration technologies can reduce transcription errors. This review examined computerized order entry systems, barcode medication administration systems, and other tools that can prevent medication transcription errors.
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.
Newspaper/Magazine Article
Prescribing errors that cause harm.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, this article recommends strategies to reduce risks associated with prescribing, including use of computerized provider order entry systems and standard order sets.
Book/Report
Report on the Safe Use of Pick Lists in Ambulatory Care Settings.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
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 > Government Resource
Attacking the Opioid Crisis Head On With Health IT.
Office of the National Coordinator for Health Information Technology.
Overdoses of opioid medications are considered an epidemic in the United States. This website provides access to various resources for hospitals and clinicians to help them address this patient safety concern. Sections include guidelines, clinical decision support, electronic prescribing, and prescription drug monitoring programs.