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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.

The Department of Veterans Affairs consistently contributes to innovation and improvement efforts in patient safety. This podcast series offers short interviews with experts in the field that explore topics such as the VA National Center for Patient Safety leadership development program and a checklist for use in mental health facilities.

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.

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.

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.

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. This website provides information about a worldwide effort to improve medication safety by examining elements of medication prescription, distribution, and use that are vulnerable. The campaign will highlight best practices to address these weaknesses.

Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.

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.

Key patient safety topics include human factors, teamwork, adverse events, communication, professionalism, and risk management. This website provides resources regarding patient safety concepts, strategies for addressing risks, and guidance for faculty using the material.

Clinician burnout can affect the ability of individuals to act safely. This website highlights the work of a collaborative across multiple organizations that seeks to develop strategies to reduce physician burnout. A recent Annual Perspective discussed the relationship between burnout and patient safety.

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.

This website provides resources to help individuals, hospitals, outpatient practices, and others improve quality and patient safety. The materials include information on collaborative projects led by the Duke Patient Safety Center and educational opportunities. Current areas of emphasis include building resilience and joy in practice. A past PSNet interview with the director of the Patient Safety Center for the Duke University Health System discussed the importance of resilience.

This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.

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.

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.

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.

Patients and families can contribute to improvement when they are treated with respect and openness. This report explored the extent to which those characteristics are present in National Health Service (NHS) investigations regarding patient deaths and found them to be lacking, particularly in cases involving patients with mental health conditions or learning disabilities. The authors recommend a framework to guide behaviors consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning.

Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis found that common problems included drug incompatibility and drug–drug interaction. The article cautions against relying on drug ordering alerts as the sole strategy for preventing potentially harmful prescribing.

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.

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.

The practice of scheduling concurrent surgeries has raised concerns about increased risks of surgeon distraction, procedure delay, and insufficient expertise available in the operating room. This United States Senate report summarizes findings of an inquiry that assessed insights from 17 hospitals regarding concurrent and overlapping surgical policies. Areas of concern identified by the investigation include a lack of available data on the patient outcomes associated with the practice and need for specific billing requirements.

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.

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.

Large-scale and individualized strategies are needed to address opioid misuse. This website provides resources related to a national initiative to improve opioid prescribing practices by obtaining physician commitment to adhere to guidelines and screening methods.

Vincristine is a chemotherapy agent that can have serious consequences if administered incorrectly. Drawing from guidelines and expert opinion regarding vincristine administration, this campaign advocates for diluting vincristine via a mini-IV drip bag to reduce the likelihood of dangerous dosage mistakes.

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.

Diagnostic error has recently been recognized as a serious patient safety concern. Established within the Armstrong Center for Patient Safety and Quality, this center seeks to raise awareness, build partnerships, and help prioritize the work of diagnostic improvement. In addition to its broad-based goals, the center will focus efforts on specific areas of concern. The first initiative will concentrate on misdiagnosis of stroke.

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.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

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.

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.

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.

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.

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.

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.

Patient Safety Organizations enable robust data collection and analysis to support learning from medical error. This website of a Patient Safety Organization dedicated to radiation safety improvement offers a mechanism for voluntary reporting of radiation oncology incident data, a searchable database, and related publications.

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.

Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.

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.

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.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

Patient safety organizations (PSO) augment learning by sharing data from voluntary reporting and informing safety interventions. This series of articles discusses PSO-related programs that resulted in improvements, such as readmission reduction.

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.

This initiative facilitates a patient safety approach that focuses on the roles of patients, clinicians, and organizations. The website provides tools and resources to inform and engage individuals as leaders to contribute to the system-oriented culture required to enhance patient safety.

Highlighting how aging affects medication absorption that may lead to complications, this fact sheet offers recommendations for older patients to follow instructions, maintain a medication list, be aware of drug interaction potential, and perform an annual review of medications with clinicians to help them take prescriptions safely.

Sepsis is a serious condition that can be rapidly fatal if it is not promptly diagnosed and treated. This foundation seeks to improve education and awareness of sepsis in the name of a pediatric patient who died when his sepsis was misdiagnosed in the emergency room.

This grant will support funding for the development, testing, and evaluation of simulation as a mechanism to identify opportunities for improvements in safety. The submission process opens November 25, 2016 and is scheduled to run until January 26, 2022.

This funding program will support research demonstration projects that explore systemic strategies to enhance medication safety. The submission process for the program is now closed.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Management and analysis of incident reporting data must be enhanced in order to realize the potential for learning and improvement from reporting activities. This publication explored primary care incidents reported in England and Wales over an 8-year period. Investigators found inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred. Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system improvements needed to optimize incident reporting as a patient safety improvement strategy.

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.

Adverse drug events related to opioid medications are a significant patient safety concern. This analysis of insurer claims data demonstrated that changing opioid prescribing requirements, including implementing patient–provider agreements, requiring prior authorization, and enforcing quantity limits, led to a decline in opioid prescribing. The authors recommend that insurers implement policies from the Centers for Disease Control and Prevention opioid guidelines to improve safety.

Sepsis has been a significant focus of quality improvement initiatives. In this retrospective review, researchers sought to identify patient characteristics, risk factors, and infections that might inform sepsis diagnosis, treatment, and prevention efforts. The medical records of a random sample of 246 adult and 79 pediatric patients with codes for severe sepsis or septic shock across 4 New York hospitals were reviewed. Investigators found that 72% of patients had exposure to at least one health care factor during the 30 days prior to being admitted for sepsis or a medical condition requiring frequent health care contact. Pneumonia was the most frequently documented infection causing sepsis. They concluded that reducing sepsis will require an ongoing focus on infection prevention.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

There is a documented interest in postgraduate professional education that enables practicing clinicians to improve the safety of their actions and behaviors. This online curriculum introduces participants to patient safety concepts and explains how they can be applied in everyday practice. Human factors engineering, workforce safety, and simulation are new areas of focus in the materials.

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.

This website provides resources exploring patient safety challenges from various perspectives, including feature length articles and measurement tools like the Surgeon Scorecard to support a community focused on driving safety improvement.

The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.

Despite the reduction of drug shortages in recent years, access to certain types of drugs, such as generic sterile injectable medications, remains limited. Analyzing data on drug shortages in the United States, this government report identifies factors that contribute to shortages and suggests prioritizing efforts to address the most pressing problems including suppliers that fail to comply with standards.

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.

Determining the preventability of an adverse event remains a challenge. Summarizing the evidence around identifying whether a hospital readmission was avoidable and if preventable readmission rates are a reasonable measure of quality and safety, this article proposes that research focus on developing quality indicators that are more relevant to patients.

This proposed rule suggests updates to the government requirements hospitals must comply with to participate in Medicare and Medicaid. Changes include emphasis on the role of leadership engagement and safety culture as ways to generate improvements in areas such as reducing hospital-acquired infections and readmissions. Comments on the proposed rule are due August 15, 2016.

Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.

The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.

Regional programs for patient safety seek to provide communities with resources targeted to distinct needs and populations while addressing key areas of concern. This institute will host an annual conference, educational opportunities, and a research program to develop innovations in patient safety.

Efforts to maintain patient autonomy can detract from ensuring residents' safety in nursing homes. Common safety issues in nursing homes are medication errors, falls, and inappropriate use of restraints. This technical brief discusses gaps in the research base that hinder understanding of the safety hazards in the residential care environment. 

Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.

Patient Safety Organizations (PSOs) were formed with provisions to protect voluntarily submitted incident data to enhance transparency and learning from medical error. Despite those expectations, PSOs still have obligations to report certain situations to external organizations. This guidance aims to clarify what and when external reporting should take place for PSOs to remain in compliance with federal requirements while appropriately protecting incident data.

Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.

Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, and teaching materials, and it has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.

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.

The National Health Service (NHS) has been a global leader in patient safety improvement since the publication of An Organization With a Memory in 2000. This government resource combines several NHS initiatives—such as the National Reporting and Learning System and the Advancing Change Team—to oversee and provide support for clinicians.

This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.

The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future state of the Veterans Health Administration, this report determined that care quality often meets or exceeds expectations but that quality varies from location to location. The authors outline recommendations for system improvements to ensure the safety of care delivery.

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.

Patient safety culture surveys uncover insights into organizational culture and practice areas that require improvement. This selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to survey results.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

Health care organizations and clinicians are aware of the unintended consequences associated with health information technology. This report summarized the evidence to provide recommendations and help hospitals develop strategies to ensure safe use of health IT systems.

This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

Defining preventability has become increasingly important due to its use as a measure for cost and reimbursement mechanisms. This report presents data on hospitalizations for conditions that might be averted through quality ambulatory care and reveals that preventable hospital stays decreased between 2005 and 2012.

Strategies to prevent medication errors are a continuing focus of ongoing safety initiatives. This guidance outlines factors to consider when creating drug products to reduce design-associated medication errors.

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.

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.

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.

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.

This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This series of trainings will prepare participants to guide their organizations through implementation of the TeamSTEPPS program.

Hospital rating programs have received significant public attention, but concerns have been raised regarding their usefulness. This website provides resources to augment usability of this data including reports describing the methodology used by the Centers for Medicare and Medicaid Services to generate the information provided on the Hospital Compare website.

Opioid pain medications carry high risk for adverse drug events and misuse. Due to climbing rates of opioid use and associated adverse events, the Centers for Disease Control and Prevention released new guidelines for prescribing opioid medications for chronic pain. These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life care. The authors recommend using opioids for chronic pain only if nonopioid medications and nonpharmacologic approaches to chronic pain are not effective and prescribing immediate-release instead of long-acting medications. For acute pain, they recommend limiting duration of therapy, stating that more than 1 week of medications should rarely be needed. The guidelines also suggest minimizing concurrent use of opioids and other sedating medications and dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids.

This analysis found that scheduling problems among patients seeking primary care from Veterans Affairs health systems continue to occur. The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary care and spotlights the need to develop and disseminate a comprehensive policy for Veterans Affairs schedulers to reduce risk of scheduling errors.

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.

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.

Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.

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.

Incident reporting has achieved varying levels of success in encouraging transparency and facilitating system learning. This publication discusses reporting initiatives in the National Health Service and focuses on the importance of considering system purpose, user experience, data integrity, and feedback process to enhance reporting systems.

The National Quality Strategy is part of AHRQ's ongoing efforts to enhance patient safety. This brief summarizes the results of the Partnership for Patients program and other initiatives working toward achieving the goals of the National Quality Strategy, including reducing hospital-acquired conditions, preventable readmissions, and patient harm.

Measuring and improving safety culture are core patient safety activities. The Agency for Healthcare Research and Quality established the Hospital Survey on Patient Safety Culture user comparative database in 2007. The 2016 report includes data from 680 hospitals. As expected, responses varied for different aspects of patient safety. In general, respondents rated teamwork, leadership, and continuous improvement as areas of strength. In contrast, handoffs, staffing, and nonpunitive response to error remained patient safety concerns for nearly half of respondents. These findings suggest that overall patient safety culture is improving at hospitals, but significant work is needed to bolster transitions, staffing, and adverse event response. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.