Patient Safety
This portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury associated with delivery of health care. Important goals include: providing information on the scope and impact of medical errors, identifying the root causes of threats to patient safety, and examining effective ways to make system-level changes to help prevent errors. Disseminating and translating research findings and methods to reduce errors are also important. Additionally, the portfolio aims to develop an environment or culture within health care settings that encourages health professionals to share and report information about medical errors and ways to prevent them.
Patient Safety Case Studies by Year
2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004
2012
Alliant/GMCF Uses AHRQ Patient Safety Surveys and TeamSTEPPS® in Nursing Homes and Hospitals
Primary Health Care Centers Use AHRQ Materials to Help Patients Use Blood Thinners Safely
Georgia QIO Uses AHRQ DVD and Brochure to Educate Medicare Patients About Safe Use of Blood Thinners
Montgomery Memorial Hospital Uses TeamSTEPPS® to Improve Emergency Care
VCU Health Systems Clinic Uses AHRQ DVD and Brochures to Educate Patients About Safe Use of Blood Thinners
Temple University Hospital Uses AHRQ Materials to Educate Patients About Safe Use of Blood Thinners
Massachusetts Hospital Improves Medication Reconciliation With AHRQ Toolkit
Georgia Hospitals Improve Medication Reconciliation Process
Two Indiana Facilities Revise Their Medication Reconciliation Process as a Result of Participating in an AHRQ Project
Maryland Hospitals Revise Medication Reconciliation Process as a Result of Participating in an AHRQ Project
Missouri Hospitals Improve Medication Reconciliation Process
Michigan Providers Improve Medication Reconciliation Process
Nebraska Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)
New Mexico Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)
New York Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)
Woodhull Medical and Mental Health Center Implements Triage System to Improve Care
Hebrew Rehabilitation Center Incorporates AHRQ's Project RED Into Demonstration Project
Cleveland Clinic Health System Facility Implements AHRQ's Emergency Severity Index
University of Kentucky HealthCare Improves Emergency Care Using Door-to-Doc Toolkit
Capital Health Influenced by AHRQ's Project RED in Creating Tool for Patients—New!
South Dakota State University Integrates TeamSTEPPS® Into College of Nursing Curriculum—New!
Tel Aviv Sourasky Medical Center Uses AHRQ's Comprehensive Unit-Based Safety Program—New!
2011
IFMC
Fletcher Allen Health Care
OSF Medical Group
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—Idaho
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—Indiana
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—Kentucky
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—New York
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—North Carolina
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—South Carolina
Preventing Hospital-Acquired Venous Thromboembolism (VTE)—Washington
Medication Reconciliation—Indiana
Medication Reconciliation—Kentucky
Medication Reconciliation—Missouri, Part 1
Medication Reconciliation—Missouri, Part 2
Medication Reconciliation—Nebraska
Medication Reconciliation—New Jersey, Part 1
Medication Reconciliation—New Jersey, Part 2
Medication Reconciliation—New Jersey, Part 3
Medication Reconciliation—New York
Medication Reconciliation—Texas
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2010
Bon Secours St. Mary's Hospital
Association of periOperative Registered Nurses
Fairview Southdale Hospital
Carilion Roanoke Memorial Hospital
North Dakota Critical Access and Network Hospitals
Clarinda Regional Health Center
Illinois Hospitals
Iowa Hospitals
New York Hospitals
Society of Hospital Medicine
Institute for Healthcare Improvement
Jennie Edmundson Hospital
Nebraska Critical Access Hospitals
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2009
National Network of Libraries of Medicine
Georgia Hospital Association
The New York City Health and Hospitals Corporation
West Virginia University Hospitals
Northwest MedStar
Mercy Hospital and Unity Hospital; Allina Hospitals and Clinics
Marshfield Clinic, Family Health Center of Marshfield, Inc.
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2008
American Society of Health-System Pharmacists
Premier Inc.
SSM Health Care
Evanston Northwestern Healthcare
Park Nicollet Health Services
Ochsner Health Systems
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2007
Aetna
Department of Defense
Campbell University School of Pharmacy
Banner Good Samaritan Medical Center
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2006
Cincinnati Children's Hospital Medical Center
HealthSouth
Voice for Patients
Hill Country Memorial Hospital; University of Texas Health Center at Tyler
University of California, Irvine, School of Medicine
Northwestern Memorial Hospital
The State of Minnesota
Multnomah County Health Department
Health Canada
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2005
New Jersey Department of Health and Senior Services
Maryland Health Care Commission
Indian River Memorial Hospital
Veterans Integrated Service Network, Upstate New York
Connecticut Hospital Association
Los Angeles County Department of Health Services
New York State Department of Health
Methodist Hospital in Southern California
SummaCare, Inc.
Creighton University
Memorial Hospital of Union County
Saint Vincent Health Center
The Leapfrog Group
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2004
Henry Ford Health System
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Current as of September 2012
Internet Citation:
Impact Case Studies and Knowledge Transfer Case Studies: Patient Safety. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/casestudies/ptsafety/index.html
540 Gaither Road Rockville, MD 20850 
