Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 46
- Culture of Safety 44
-
Education and Training
52
- Students 1
- Error Reporting and Analysis 56
- Human Factors Engineering 18
-
Legal and Policy Approaches
29
-
Incentives
13
- Financial 11
-
Incentives
13
- Logistical Approaches 8
-
Quality Improvement Strategies
82
- Benchmarking 17
- Specialization of Care 2
- Teamwork 14
- Technologic Approaches 40
Safety Target
- Device-related Complications 8
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 19
- Fatigue and Sleep Deprivation 3
- Interruptions and distractions 1
- Medical Complications 30
- Medication Safety 37
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 12
Clinical Area
-
Medicine
130
-
Internal Medicine
59
- Geriatrics 11
- Primary Care 16
- Surgery 12
-
Internal Medicine
59
- Nursing 4
- Pharmacy 11
Target Audience
Origin/Sponsor
-
North America
-
United States of America
-
United States Federal Government
-
Department of Health and Human Services (HHS)
- Agency for Healthcare Research and Quality (AHRQ)
-
Department of Health and Human Services (HHS)
-
United States Federal Government
-
United States of America
Search results for "Agency for Healthcare Research and Quality (AHRQ)"
- Web Resource
- Agency for Healthcare Research and Quality (AHRQ)
Download Citation File:
- View: Basic | Expanded
- Sort: Best Match | Most Recent
Audiovisual > Audiovisual Presentation
The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety.
Rockville, MD: Agency for Healthcare Research and Quality; July 2016.
This toolkit provides resources to help hospitals to augment safety. The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition from ICD-9 to ICD-10, experience from testing in hospitals, and materials targeted to inform leadership of the program. The toolkit is structured around enhancing multidisciplinary teamwork by completing a series of steps such as assessing the organizational readiness for a change initiative, implementing improvements, and determining the return on investment of the programs.
Web Resource > Government Resource
Quality and Patient Safety.
Agency for Healthcare Research and Quality.
The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide range of patient safety resources collected by AHRQ, including a new section summarizing their involvement in understanding diagnostic error.
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.
Tools/Toolkit > Government Resource
TeamSTEPPS for Office-Based Care Version.
Rockville, MD: Agency for Healthcare Research and Quality; April 2016.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.
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.
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.
Tools/Toolkit > Multi-use Website
TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.
- Classic
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 > Fact Sheet/FAQs
Choosing a Patient Safety Organization: Tips for Hospitals and Health Care Providers.
Rockville, MD: Agency for Healthcare Research and Quality; January 2016. AHRQ Publication No. 16-0014-EF.
Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.
Book/Report
Saving Lives and Saving Money: Hospital-Acquired Conditions Update.
- Classic
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
Tools/Toolkit > Government Resource
Toolkit for Reducing CAUTI in Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.
Book/Report
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
- Classic
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Web Resource > Course Material/Curriculum
TeamSTEPPS 2.0 Core Curriculum.
Rockville, MD: Agency for Healthcare Research and Quality; September 2015.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.
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.
Tools/Toolkit > Government Resource
Hospital inpatients' experiences: percentage of parents who reported how often providers prevented mistakes and helped them to report concerns.
Rockville, MD: National Quality Measures Clearinghouse; December 2015.
Parents can help to recognize and report problems that occur when their children receive inpatient care. This quality measure has been developed to assist hospitals in tracking how often clinicians prevent mistakes while providing care for pediatric patients and whether they inform parents about ways to report concerns.
Audiovisual > Audiovisual Presentation
Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.
Agency for Healthcare Research and Quality. July 15, 2015.
Ambulatory surgery centers have been the focus of patient safety concerns due to high-profile incidents of harm. This webinar highlighted the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture, results of its pilot test, and insights from hospitals using the survey.
Tools/Toolkit > Fact Sheet/FAQs
Your Medicine, Be Smart, Be Safe.
Patient Guide. Rockville, MD: Agency for Healthcare Research and Quality, Bethesda, MD: National Council on Patient Information and Education; July 2015. AHRQ Publication No. 11-0049-A.
This Web site assists consumers in learning how to take medications safely. The materials answer common questions about medication use and includes forms and a wallet card for tracking relevant information. The material is available in both English and Spanish.
Book/Report
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report.
Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2015. AHRQ Publication No. 15-0041-EF.
This survey expands AHRQ's patient safety culture work to the community pharmacy setting. Approximately 1600 pharmacy staff from 255 community pharmacies voluntarily completed the survey between 2013 and 2014. The database is meant to allow for comparison and benchmarking of safety cultures across pharmacies. However, the current response rate represents less than 1% of total community pharmacies in the United States, and more than half of respondents were chain drugstores or integrated health systems. Most community pharmacies scored well for patient counseling and communication openness, while staffing, work pressure, and pace represented the biggest areas for potential improvement. A prior AHRQ WebM&M interview with J. Bryan Sexton explored the relationship between culture and patient safety.
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
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
- Classic
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
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.