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Search results for "Department of Health and Human Services (HHS)"

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Web Resource > Multi-use Website

AHRQ Safety Program for Improving Surgical Care and Recovery.

Rockville, MD: Agency for Healthcare Research and Quality.

Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-based Safety Program to help hospitals integrate best practices into all stages of surgery to ensure safe recovery. Targeted areas of improvement include safety culture development, teamwork skills, and partnering with patients.

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

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

Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families.

Rockville, MD: Agency for Healthcare Research and Quality; April 2017.

Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.

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.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

Journal Article > Government Resource

Increases in drug and opioid overdose deaths—United States, 2000–2015.

  • Classic

Rudd RA, Seth P, David F, Scholl L. MMWR Morb Mortal Wkly Rep. 2016;65:1445-1452.

Opioid medications are frequently associated with adverse drug events in inpatient and outpatient settings. This surveillance report from the Centers for Disease Control and Prevention demonstrated that the magnitude of patient harm from opioid use is growing rapidly. Opioid overdose deaths are increasing each year, through 2015, and current rates are the highest ever recorded. The types of opioids most commonly involved in overdose deaths are natural and semisynthetic opioids, which are often prescribed as pain relievers. The authors suggest that the adoption of new prescribing guidelines and more widespread use of the opioid reversal agent naloxone will help address this growing epidemic. An earlier version of this article included data through 2014. A previous WebM&M commentary described a fatal opioid overdose.

Book/Report

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014.

Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.

Grant > Government Resource

Improving Patient Safety Through Learning Laboratories.

Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

Collaborative strategies can enable individuals and organizations to learn from each other to support patient safety improvement. This fact sheet summarizes 13 projects launched through Agency for Healthcare Research and Quality funding designed for rapid deployment through team-focused learning laboratories to test and apply systems engineering approaches to improve safety in health care.

Audiovisual > Audiovisual Presentation

Using Just Culture to Improve Results on the AHRQ Hospital Survey on Patient Safety Culture.

Agency for Healthcare Research and Quality. November 9, 2016.

A just culture balances organizational context with appropriate accountability after an error. This webinar discussed how organizations can implement just culture principles to improve their results on the Hospital Survey on Patient Safety Culture.

Book/Report

Nursing Home Antimicrobial Stewardship Guide.

Rockville, MD: Agency for Healthcare Research and Quality; October 2016.

Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.

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.

Web Resource > Multi-use Website

Improving Diagnostic Accuracy Project 2016–2017.

Washington, DC: National Quality Forum; October 2016.

The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This website provides the information about a project that has convened an expert panel to identify and develop new measures to help address weaknesses in testing and tracking diagnostic accuracy. The program is currently accepting comments regarding the program framework. The submission deadline is July 12, 2017.

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.

Book/Report

Patient Safety in Ambulatory Settings.

  • Classic

Shekelle, PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care and notes that studies on patient engagement and diagnostic error are lacking.

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.

Book/Report

AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report.

Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.

The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in the nursing home setting. The 2016 user comparative database report summarizes survey data obtained from 12,395 staff and provider respondents working in 209 nursing homes. The report highlights two areas of safety culture in which nursing homes appear to do well: overall perceptions of resident safety and feedback and communication about incidents. Areas identified as needing improvement across most nursing homes included staffing issues and ensuring a nonpunitive response to mistakes. A previous PSNet perspective provided insights on safety culture.

Book/Report

Healthcare Simulation Dictionary.

Lopreiato JO, Downing D, Gammon W, et al; Terminology & Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16(17)-0043.

Developed by AHRQ in partnership with the Society for Simulation in Healthcare, this dictionary represents an effort to standardize language associated with simulation in order to improve communication about and application of the strategy. The terms in the initial collection will be expanded and revised over time.

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.

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