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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.