The Accountability Conundrum: Staying Focused, Delivering Results; A Report on the UHC 2008 Quality and Safety Forum. J. Clarke, editor, American Journal of Medical Quality, March/April 2009; 24(2 Suppl):5S-43S. Presents a synthesis of presentations from the University HealthSystem Consortium's 2008 quality and safety forum, including an article by AHRQ's director that describes AHRQ's efforts in knowledge creation, synthesis, and dissemination of findings related to patient safety and health care quality improvement. (AHRQ 09-R055)
Advances in Patient Safety: From Research to Implementation. Agency for Healthcare Research and Quality and U.S. Department of Defense, April 2005. Four-volume set on CD-ROM covers new patient safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors and harm. CD-ROM Volumes 1-4 (AHRQ 05-0021-CD)
Advances in Patient Safety: New Directions and Alternative Approaches. Agency for Healthcare Research and Quality, August 2008. Four volume set comprises 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Available in print (single copies of 4-volume set or individual volumes available free) and as a searchable CD-ROM. (AHRQ 08-0034) CD-ROM Volumes 1-4. (AHRQ 08-0034-CD)
Advancing Patient Safety: A Decade of Evidence Design and Implementation. Agency for Healthcare Research and Quality, November 2009, 12 pp. Briefly describes AHRQ's contributions in advancing patient safety over the past decade. (AHRQ 09(10)-0084)
Adverse Event Reporting Practices by U.S. Hospitals: Results of a National Survey. D. Farley, A. Haviland, S. Champagne, et al., Quality and Safety in Health Care, December 2008; 17(6):416-423. Reports on the results of a national survey of 2,050 non-Federal U.S. hospitals that gathered baseline data on the characteristics of systems and processes the hospitals were using for adverse event reporting for use in assessing improvement in reporting. (AHRQ 09-R021)
Adverse Event Reporting Systems and Safer Healthcare. J. Battles, D. Stevens, Quality and Safety in Health Care, February 2009; 18(1):2. Editorial discusses the potential of adverse event reporting systems to improve patient safety and the slow progress that has been made thus far in implementing such systems. (AHRQ 09-R043)
Alleviating “Second Victim” Syndrome: How We Should Handle Patient Harm. C. Clancy, Journal of Nursing Care Quality, January-March 2012; 27(1):1-5. Commentary describes how a health care worker can become a second victim of a medical error and the critical importance of disclosure in improving patient safety. (AHRQ 12-R030)
Applying Trigger Tools to Detect Adverse Events Associated with Outpatient Surgery. A. Rosen, H. Mull, H. Kaafarani, et al., Journal of Patient Safety, March 2011; 7(1):45-59. Evaluates the performance of five triggers to detect adverse events associated with outpatient surgery. (AHRQ 11-R042)
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Agency for Healthcare Research and Quality, February 2008, 36 pp. Discusses five key high reliability concepts and tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals to improve patient safety and care. Key concepts include sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, and resilience. (AHRQ 08-0022)
The Canary's Warning: Why Infections Matter. C. Clancy, American Journal of Medical Quality, November/December 2009; 24(6):462-464. Editorial focuses on measures used to screen for adverse events that patients may experience while in the health care system, particularly the usefulness of a measure of infections due to medical care. (AHRQ 10-R018)
CMS's Hospital Acquired Condition Lists Link Hospital Payment, Patient Safety. C. Clancy, American Journal of Medical Quality, March/April 2009; 24(2):166-168. Commentary discusses the Centers for Medicare & Medicaid Services' (CMS') change in policy that denies hospital payment for certain preventable adverse events that are the result of the hospital's care and the policy implications of this change, as well as its potential for quality improvement. (AHRQ 09-R054)
Consensus-Based Recommendations for Research Priorities Related to Interventions to Safeguard Patient Safety in the Crowded Emergency Department. C. Fee, K. Hall, J. Morrison, et al., Academic Emergency Medicine, December 2011; 18(12):1283-1288. Summarizes the results of the Interventions to Safeguard Safety breakout session of the 2011 consensus conference “Interventions to Assure Quality in the Crowded Emergency Department” and identifies seven research priorities for maintaining safety in that setting. (AHRQ 12-R033)
The Cost and Incidence of Prescribing Errors Among Privately Insured HIV Patients. F. Hellinger, W. Encinosa, Pharamacoeconomics, January 2010; 28(1):23-34. Examines the cost and frequency of antiretroviral prescribing errors among a sample of privately insured patients with HIV disease. (AHRQ 10-R044)
Do Patient Safety Events Increase Readmissions? B. Friedman, W. Encinosa, H. Jiang, et al., Medical Care, May 2009; 47(5):583-590. Examines the effects of adverse safety events in the hospital on risks of death and readmission. (AHRQ 09-R051)
DoD Medical Team Training Programs: An Independent Case Study Analysis. Agency for Healthcare Research and Quality and Department of Defense, May 2006, 57 pp. Describes results of an evaluation of three Department of Defense (DoD)-sponsored medical team training programs. (AHRQ 06-0001) Companion to Medical Teamwork and Patient Safety: The Evidence-Based Relation (AHRQ 06-0053)
Establishing a Global Learning Community for Incident-Reporting Systems. J. Pham, S. Gianci, J. Battles, et al., Quality and Safety in Health Care, October 2010; 19(5):446-451. Offers guidance through a presentation of expert discussions about methods to identify, analyze, and prioritize incidents, mitigate hazards, and evaluate risk reduction. (AHRQ 11-R018)
From Research to Practice: Factors Affecting Implementation of Prospective Targeted Injury-Detection Systems. A Sorensen, M. Harrison, H. Kane, et al., British Medical Journal of Quality and Safety, June 2011; 20(6):527-533. Describes key factors that shaped implementation of prospective targeted injury-detection systems for adverse drug events and nosocomial pressure ulcers at five hospitals. (AHRQ 11-R069)
Guide for Developing a Community-Based Patient Safety Advisory Council. Agency for Healthcare Research and Quality, March 2008, 50 pp. Provides information and guidance that individuals and organizations can use to develop community-based advisory councils to bring about improvements in patient safety through education, collaboration, and consumer engagement. (AHRQ 08-0048)
Hospital Survey on Patient Safety Culture. Agency for Healthcare Research and Quality, September 2004, 75 pp. Includes a review of the literature pertaining to safety issues, accidents, medical errors, error reporting, and the safety climate of hospital environments. The final survey was pilot tested with more than 1,400 hospital employees across the United States, and includes information on sample group selection, data collection, and interpreting results. (AHRQ 04-0041)
Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. Agency for Healthcare Research and Quality, February 2012, 69 pp. Presents survey results for 1,128 hospitals and 567,703 hospital staff respondents, as well as a chapter on trending that shows change over time for 650 hospitals that administered the survey and submitted data more than once. (AHRQ 12-0017)
The Human Factors of Home Health Care: A Conceptual Model for Examining Safety and Quality Concerns. K. Henriksen, A. Joseph, T. Zayas-Caban, Journal of Patient Safety, December 2009; 5(4):229-236. Examines the human factors challenges associated with providing home health care to an aging population that is steadily increasing in number and longevity. (AHRQ 10-R020)
Incidence and Types of Non-Ideal Care Events in an Emergency Department. K. Hall, S. Schenkel, J. Hirshon, et al., Quality and Safety in Health Care, October 2010; 19(Suppl 3):i20-i25. Identifies and characterizes hazardous conditions in the emergency department of an urban, academic tertiary care medical center. (AHRQ 11-R015)
Incorrect Surgical Procedures Within and Outside of the Operating Room: A Follow-Up Report. J. Neily, P. Mills, N. Eldridge, et al., Archives of Surgery, November 2011; 146(11):1235-1239. Describes incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and builds on previously reported events from 2001 to mid-2006. (AHRQ 11-R076)
Medical Office Survey on Patient Safety Culture. Agency for Healthcare Research and Quality, November 2008, 54 pp. Presents materials for a survey that is designed to measure patient safety culture in an individual medical office by assessing the opinions of staff at all levels, from physicians to receptionists. Includes guidance on how to collect and report data, as well as how to conduct a Web-based survey. (AHRQ 08(09)-0059)
Mistake-Proofing the Design of Health Care Processes. Agency for Healthcare Research and Quality, May 2007, CD-ROM. Provides an in-depth introduction to mistake-proofing, a little-known but very promising approach to preventing medical errors and reducing the adverse events that result from errors. May 2007 (07-0020-CD).
More Work Is Needed to Protect Medical Residents from Fatigue and Potential Errors, IOM Report Finds. C. Clancy, American Journal of Medical Quality, May/June 2009; 24(3):259-261. Commentary briefly discusses a recent AHRQ-funded report by the Institute of Medicine on the effects of sleep deprivation among medical residents, presents recommendations for addressing acute and chronic fatigue among these providers, and describes AHRQ's evidence-based tools to help hospitals assess and improve their patient safety culture and teamwork. (AHRQ 09-R065)
New Patient Safety Culture Survey Helps Medical Offices Assess Awareness. C. Clancy, American Journal of Medical Quality, September/October 2009; 24(5):441-443. Discusses the development and features of AHRQ's new Medical Office Survey on Patient Safety Culture, a tool to assist medical offices in evaluating staff's understanding of patient safety issues. (AHRQ 10-R001)
New Patient Safety Organizations Can Help Providers Learn From and Reduce Patient Safety Events. C. Clancy, Journal of Patient Safety, March 2009; 5(1):1-2. Discusses the roles and responsibilities of patient safety organizations and invites interested organizations to join the program. (AHRQ 09-R049)
New Patient Safety Organizations Lower Roadblocks to Medical Error Reporting. C. Clancy, American Journal of Medical Quality, 23:2008; 318-321. Discusses the importance of sharing information about events that jeopardize patient safety and the role of clinicians and patient safety organizations, working within a protected legal environment, in sharing information about medical errors and near misses to facilitate better error prevention strategies. (AHRQ 09-R002)
New Research Highlights the Role of Patient Safety Culture and Safer Care. C. Clancy, Journal of Nursing Care Quality, July/September 2011; 26(3):193-196. Commentary discusses patient safety in nursing practice and emphasizes expansion of a patient safety culture from the nursing unit to the entire organization and the influence of a learning climate on error-producing conditions and medication errors in nursing units. (AHRQ 11-R070)
Nursing Home Survey on Patient Safety Culture. Agency for Healthcare Research and Quality, November 2008, 52 pp. Presents a survey designed to measure resident safety culture in a nursing home facility or in a special contained area of a facility that includes only licensed nursing home beds. Guidance is provided for data collection and reporting. (AHRQ 08(09)-0060)
Partial Truths in the Pursuit of Patient Safety. K. Henriksen, Quality and Safety in Health Care, October 2010; 19(Suppl 3):i3-i7. Explores several issues in the form of partial truths that dominate current thinking as researchers continue their patient safety efforts. (AHRQ 11-R016).
Patient Safety and Medical Liability Reform: Putting the Patient First. C. Clancy, Patient Safety & Quality Healthcare, September/October 2010; 7(5):6-7. Presents background information on medical liability reform and discusses AHRQ's new Patient Safety and Medical Liability Initiative launched in June 2010. (AHRQ 11-R035)
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, April 2008, 1,400 pp. This three-volume resource, available in print and as a searchable CD-ROM, contains 89 contributions that represent the work of a broad range of nurses and other patient safety researchers, spanning a range of issues applicable to a variety of health care settings. (AHRQ 08-0043) CD-ROM (AHRQ 08-0043-CD)
Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety. Agency for Healthcare Research and Quality and Department of Veterans Affairs, August 2007. A DVD that provides a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level. The DVD presents eight modules that depict processes and tools that can be used to develop a systems-based approach to patient safety including: investigation of medical errors and their root causes; identification, implementation, and evaluation of system-level interventions to address patient safety concerns; and steps necessary to promote a culture of safety within a hospital or other health care facility. (AHRQ 07-0035-DVD)
AHRQ Patient Safety Network—A National Patient Safety Resource
The AHRQ Patient Safety Network (AHRQ PSNet) is a Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings and other useful information. AHRQ PSNet provides powerful searching and browsing capability, as well as the ability to customize the site around users' interests ("My PSNet").
To learn more and watch a video tutorial of the site's enhanced navigation features, visit http://www.psnet.ahrq.gov. |
Pharmacists Emerge as Key Stakeholders in Quality, Patient Safety Efforts. C. Kelly, C. Clancy, Journal of the American Pharmacists Association, March/April 2009; 49(2):146-150. Presents information about AHRQ's involvement in promoting the role of pharmacists in patient safety, studies underway to evaluate pharmacy services, the ability of emergency pharmacists to reduce medication errors, and efforts to improve health literacy with regard to patients' understanding of the medications they are prescribed. (AHRQ 09-R057)
Problems and Prevention: Chest Tube Insertion. Agency for Healthcare Research and Quality and University of Maryland School of Medicine, September 2006, 11-minute DVD. Uses video excerpts of 50 actual chest tube insertion procedures to illustrate problems that can occur and provides correct techniques for inserting chest tubes. (AHRQ 06-0069-DVD)
Racial Disparities in the Frequency of Patient Safety Events: Results from the National Medicare Patient Safety Monitoring System. M. Metersky, D. Hunt, R. Kliman, et al., Medical Care, May 2011; 49(5):504-510. Examines whether there are racial disparities in the frequency of adverse events studied in the Medicare Patient Safety Monitoring System. (AHRQ 11-R050)
Reducing Health Care Hazards: Lessons from the Commercial Aviation Safety Team. P. Pronovost, C. Goeschel, K. Olsen, et al., Health Affairs, April 2009; 28(3):w479-w489. Explores the usefulness of a public-private partnership—similar to that used by the aviation industry—to coordinate national efforts to improve quality of care and patient safety. (AHRQ 10-R021)
Reengineering Hospital Discharge: A Protocol to Improve Patient Safety, Reduce Costs, and Boost Patient Satisfaction. C. Clancy, American Journal of Medical Quality, July/August 2009; 24(4):344-346. Commentary focuses on the redesign of hospital discharge protocols and the effects that can have on reducing readmissions, lowering costs, and improving patient safety and patient satisfaction. (AHRQ 09-R082)
The Science of Safety Improvement: Learning While Doing. C. Clancy, D. Berwick, Annals of Internal Medicine, May 2011; 154(10):699-700. Editorial discusses the challenges associated with designing patient safety research and evaluation projects that can better assist hospitals and clinicians who aspire to provide high-quality, safe care to patients. (AHRQ 11-R060)
TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety
Agency for Healthcare Research and Quality and Department of Defense, September 2006. A comprehensive set of ready-to-use materials and training curricula for health care organizations provides techniques to improve the ability of teams to respond quickly and effectively to high-stress situations.
Guide to Action. November 2008, 25 pp. Presents an overview of the TeamSTEPPS system—including principles, methodologies, training curricula, and resources—and briefly discusses the TeamSTEPPS scientific foundation. (AHRQ 06-0020-4; single copies free)
Instructor Guide. 794 pp., explains how to conduct a pre-training assessment of an organization's training needs, how to present the information effectively, and how to manage organizational change. Includes printed materials in a 3-inch loose-leaf binder, plus the Multimedia Resource Kit and the Pocket Guide (see below). (AHRQ 06-0020-0; single copies $12.00 for shipping to addresses within the U.S.)
Multimedia Resource Kit. Includes contents of the Instructor Guide and the Pocket Guide as printable files (Word®, PDF, and PowerPoint®), plus a DVD that contains nine video vignettes. (AHRQ 06-0020-3; single copies free)
Pocket Guide. Spiral-bound, 36 pp., summarizes TeamSTEPPS principles in a portable, easy-to-use format. (AHRQ 06-0020-2; single copies free)
Poster. 17 x 22 inches, tells your staff you are adopting TeamSTEPPS (AHRQ 06-0020-5; single copies free)
Rapid Response System Module. March 2009, CD. Provides an overview of the Rapid Response System and the role of the Rapid Response Team, which comprises clinicians who bring critical care expertise to patients requiring immediate treatment while in the hospital. Includes curriculum slides, an instructor guide, and video vignettes. (AHRQ 08(09)-0074-CD; single copies free) |
Ten Years After To Err Is Human. C. Clancy, American Journal of Medical Quality, November/December 2009; 24(6):525-528. Commentary discusses progress made in reducing medical errors in the 10 years since the Institute of Medicine's sentinel report, To Err Is Human, and describes patient safety work done by AHRQ during those years. (AHRQ 10-R019)
Testing the Association Between Patient Safety Indicators and Hospital Structural Characteristics in VA and Nonfederal Hospitals. P. Rivard, A. Elixhauser, C. Christiansen, et al., Medical Care Research and Review, June 2010; 67(3):321-341. Examines the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. (AHRQ 10-R027)
Tools to Alleviate Safety Concerns. C. Clancy, Trustee, November/December 2009; 19(6):390-397. AHRQ director discusses the Agency's patient safety mission and goals and highlights tools and other resources available from AHRQ to facilitate hospital quality improvement efforts. (AHRQ 10-R028)
Towards a Safer Healthcare System. K. Henriksen, S. Albolino, Quality and Safety in Health Care, October 2010; 19(Suppl 3):i1-i2. Presents introductory remarks for a journal supplement focused on the interplay between ergonomics, human factors, and patient safety. (AHRQ 11-R017)
Transforming Healthcare: A Safety Imperative. L. Leape, D. Berwick, C. Clancy, et al., Quality and Safety in Health Care, December 2009; 18(6):424-428. Introduces five concepts fundamental to improving patient safety-transparency, care integration, patient/consumer engagement, restoration of joy and meaning in work, and medical education reform-and discusses the meaning and implications of each as a component of a vision for health care safety improvement. (AHRQ 10-R035)
Transforming Hospitals: Designing for Safety and Quality (DVD). Agency for Healthcare Research and Quality, September 2007. Reviews the case for evidence-based hospital design and how it can increase patient and staff satisfaction and safety, quality of care, and employee retention, as well as how it results in a positive return on investment. Describes the experiences of three modern hospitals that incorporated evidence-based design elements into their construction and renovation projects. (AHRQ 07-0076-DVD)
Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary. Agency for Healthcare Research and Quality, February 2009; 50 pp. Presents background information on the development and implementation of clinical triggers and targeted injury detection systems to identify patient safety risks and hazards. Includes eight papers presented at a 2008 AHRQ-sponsored conference focused on triggers and TIDS. (AHRQ 09-0003)
AHRQ WebM&M—Morbidity and Mortality Rounds on the Web
AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is the online journal and forum on patient safety and health care quality. This site features expert analysis of medical errors reported anonymously by our readers, Perspectives on Safety, and interactive learning modules on patient safety ("Spotlight Cases"). CME and CEU credits are available.
To learn more, visit http://www.webmm.ahrq.gov. |
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