Patient Safety/Medical Errors

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 24(2 Suppl):March/April 2009, 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)

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, 17(6):December 2008, 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 18(1):February 2009, 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)

Agency for Healthcare Research and Quality's National Quality and Disparities Reports Emphasize Patient Safety. C. Clancy, D. McNeill, E. Moy, et al., Journal of Patient Safety 2(2): June 2006, 70-71. Commentary reviews the implications of the National Quality and Disparities Reports for patient safety. Reports focus attention on patient safety and offer a set of measures that provide useful trend information and comparative data. (AHRQ 07-R013)

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)

Care Transitions: A Threat and an Opportunity for Patient Safety. C. Clancy, American Journal of Medical Quality 21(6): November/December 2006, 415-417. Discusses the pros and cons of using medical teams to reduce errors and ways to make safer patient handoffs from one care setting to another. (AHRQ 07-R026)

CMS's Hospital Acquired Condition Lists Link Hospital Payment, Patient Safety. C. Clancy, American Journal of Medical Quality 24(2):March/April 2009, 166-168. Commentary discusses the Centers for Medicare & Medicaid Services' 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)

Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. E. Dayton, K. Henriksen, Joint Commission Journal on Quality and Patient Safety 33(1): January 2007, 34-47. Discusses the role of communication failures in medical errors and how more structured and explicitly designed forms of communication could reduce ambiguity and enhance clarity in health care settings. (AHRQ 07-R049)

Cost-Effective Enhancement of Claims Data to Improve Comparisons of Patient Safety. H. Jordan, M. Pine, A. Elixhauser, et al., Journal of Patient Safety 3(2): June 2007, 82-90. Describes AHRQ's Patient Safety Indicators and how they can be used in conjunction with clinical data as a tool to screen for medical errors. (AHRQ 07-R063)

Designing for Safety: Evidence-Based Design and Hospitals. C. Clancy, American Journal of Medical Quality 23(1): January/February 2008, 66-69. Discusses how evidence-based design principles can contribute to safer care for hospitalized patients. (AHRQ 08-R035)

Do Patient Safety Events Increase Readmissions? B. Friedman, W. Encinosa, H. Jiang, et al., Medical Care 47(5):May 2009, 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-sponsored medical team training programs. (AHRQ 06-0001) Companion to Medical Teamwork and Patient Safety: The Evidence-Based Relation (AHRQ 06-0053)

Evidence Shows Cost and Patient Safety Benefits of Emergency Pharmacists. C. Clancy, American Journal of Medical Quality 23(3): May/June 2008, 231-233. Discusses the role of emergency pharmacists in hospital emergency care settings, the effects on reducing adverse drug events, cost savings, and staff acceptance, as well as suggestions for implementing emergency pharmacist programs. (AHRQ 08-R080)

Forging a New Path to Medication Safety with Emergency Pharmacists. C. Clancy, Journal of Patient Safety 4(1): March 2008, 1-2. Invited commentary that discusses the emergence of the emergency pharmacist and two new initiatives to assist pharmacists and hospitals in getting support for and implementing emergency pharmacist programs. (AHRQ 08-R055)

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: 2009 Comparative Database Report. Agency for Healthcare Research and Quality, March 2009, 92 pp. Updates the 2008 report and includes results from 622 hospitals and nearly 200,000 hospital staff respondents who completed the survey. Also includes a new chapter on trending that presents results showing change over time for 98 hospitals that administered the survey multiple times. (AHRQ 09-0030)

Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report. Agency for Healthcare Research and Quality, February 2008, 77 pp. Updates the 2007 report and includes more data, including results from a total of 519 hospitals and 160,176 hospital staff respondents who completed the survey. Also includes a new chapter on trending that presents results showing change over time for 98 hospitals that administered the survey and submitted data twice. (AHRQ 08-0039)

Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. Agency for Healthcare Research and Quality, April 2007, 102 pp. Presents statistics on the patient safety culture areas or composites assessed in the Hospital Survey on Patient Safety Culture and averages for breakouts of the data by hospital and respondent characteristic. Allows hospitals to compare their data with data from other similar hospitals. (AHRQ 07-0025)

How Often Are Potential Patient Safety Events Present on Admission. R. Houchens, A. Elixhauser, P. Romano, Joint Commission Journal on Quality and Patient Safety 34(3): March 2008, 154-163. Evaluates the use of information on whether diagnoses are present at the time of hospital admission to assess the face validity of present-on-admission (POA) information in two States (California and New York), evaluates the relationship between POA information and the AHRQ Patient Safety Indicators (PSIs), and examines defined without POA information are valid measures of hospital-level quality of care. (AHRQ 08-R069)

How Useful Are Voluntary Medication Error Reports? The Case of Warfarin-Related Medication Errors. C. Zhan, S. Smith, M. Keyes, et al., Joint Commission Journal on Quality and Patient Safety 34(1): January 2008, 36-45. Analyzes warfarin medication errors reported by hospitals and clinics participating in a voluntary medication errors reporting system, MEDMARX. Study objectives were to explore the value and proper use of voluntary medical error reports and to learn more about common errors in warfarin use. (AHRQ 08-R047)

The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients. W. Encinosa, F. Hellinger, Health Services Research, July 2008, online. Examines the effects of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery. (AHRQ 08-R079)

Improving Patient Safety by Instructional Systems Design. J. Battles, Quality and Safety in Health Care, 15(Suppl 1):2006, 25-29. Discusses how patient safety training itself sometimes contributes to the risks and hazards of health care associated injuries. Examines the principle of safety by design and the application of established design principles to patient safety education and training programs. (AHRQ 07-R044)

Improving the Complex Nature of Care Transitions. R. Hughes, C. Clancy, Journal of Nursing Care Quality 22(4):2007, 289-292. Discusses the potential for medical errors associated with shift handovers and patient transfers, presents findings from some recent studies focused on patient transitions, and identifies remaining challenges in this area. (AHRQ 08-R014)

Improving the Health Care Work Environment: A Sociotechnical Systems Approach. M. Harrison, K. Henriksen, R. Hughes, Joint Commission Journal on Quality and Patient Safety 33(11 Suppl): November 2007, 3-6. Discusses the use of a sociotechnical systems approach to improve the health care work environment and introduces a special journal supplement on this topic. (AHRQ 08-R022)

Improving the Health Care Work Environment: Implications for Research, Practice, and Policy. M. Harrison, K. Henriksen, R. Hughes, Joint Commission Journal on Quality and Patient Safety 33(11 Suppl): November 2007, 81-84. Discusses how physical settings and conditions—such as room layout, light, and noise—interact with the organization and delivery of health care and explains how the physical environment directly and indirectly affects patients' care outcomes and practitioners' behavior and well-being. (AHRQ 08-R026)

Initiating Transformational Change to Enhance Patient Safety. K. Henriksen, M. Keyes, D. Stevens, et al., Journal of Patient Safety 2(1): March 2006, 20-24. Explores what transformational change means with respect to patient safety and quality initiatives and examines lessons learned as found in the management and transformation change literature. (AHRQ 07-R003)

The Intensive Care Unit, Patient Safety, and the Agency for Healthcare Research and Quality. C. Clancy, American Journal of Medical Quality 21(5): September-October 2006, 348-351. Highlights some of the major issues in intensive care unit safety, including difficult working conditions that make errors more probable, and describes AHRQ-supported research and other activities in the patient safety area. (AHRQ 07-R001)

Limiting Nurse Overtime and Promoting Other Good Working Conditions Influences Patient Safety. B. Sharp, C. Clancy, Journal of Nursing Care Quality, 23(2): April-June 2008, 97-100. Commentary discusses the relationship between nurse staffing level and patient outcomes, the effect of nursing overtime on patient outcomes, and the role of nurse fatigue in medical errors. (AHRQ 08-R065)

Medicaid Markets and Pediatric Patient Safety in Hospitals. R. Smith, R. Cheung, P. Owens, et al., Health Services Research, 42(5): October 2007, 1981-1997. Compares the association between Medicaid market characteristics and the occurrence of potentially preventable adverse medical events in hospitalized children in Florida, New York, and Wisconsin in the years 1999-2001. (AHRQ 08-R018)

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)

Medicare Payment for Selected Adverse Events: Building the Business Case for Investing in Patient Safety. C. Zhan, B. Friedman, A. Mosso, et al., Health Affairs 25(5): September/October 2006, 1386-1393. Provides insights into the intricate financial relationships surrounding adverse events and illustrates the business cases for both Medicare and hospitals to invest in patient safety. (AHRQ 07-R008)

Mistake-Proofing in Health Care: Lessons for Ongoing Patient Safety Improvements. C. Clancy, American Journal of Medical Quality 22:2007, 463-465. Discusses the role and importance of mistake-proofing in creating a culture of patient safety in health care organizations. (AHRQ 08-R016)

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).

New Patient Safety Organizations Can Help Providers Learn From and Reduce Patient Safety Events. C. Clancy, Journal of Patient Safety 5(1):March 2009, 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)

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)

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)

Patient Safety in Nursing Practice. M. Farquhar, B. Sharp, C. Clancy, AORN Journal 86(3(): September 2007, 455-457. Discusses AHRQ-supported research focused on the role of nurses in improving patient safety and quality of care. (AHRQ 08-R019)

Patient Safety in the Intensive Care Unit: Challenges and Opportunities. C. Clancy, Journal of Patient Safety 3(1): March 2007, 6-8. Commentary on the occurrence of errors in hospital ICUs, as well as examples of research in this area funded by the Agency for Healthcare Research and Quality. (AHRQ 07-R054)

Pharmacists Emerge as Key Stakeholders in Quality, Patient Safety Efforts. C. Kelly, C. Clancy, Journal of the American Pharmacists Association 49(2):March/April 2009, 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)

Putting the Patient in Patient Safety. C. Clancy, Journal of Patient Safety 3(2): June 2007, 65-66. Discusses the importance of patient participation in health care decisionmaking as one of the key factors in reducing medical errors and improving patient safety. (AHRQ 07-R076)

Sleepless in the Hospital: Evidence Mounts that Tired Caregivers May Compromise Quality. C. Clancy, Journal of Patient Safety 3(3): September 2007, 125-126. Comments on recent evidence on the relationship between extra long shifts without sleep for residents and interns and the occurrence of preventable adverse events in hospitals. (AHRQ 08-R007)

TeamSTEPPS™: Assuring Optimal Teamwork in Clinical Settings. C. Clancy, D. Tornberg, American Journal of Medical Quality 22(3): May/June 2007, 214-217. Discusses the importance of teamwork in promoting high quality health care and preventing medical errors and describes the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™) training resource, which is sponsored jointly by AHRQ and the Department of Defense. (AHRQ 07-R024)

TeamSTEPPS™: Optimizing Teamwork in the Perioperative Setting. C. Clancy, AORN Journal 86(1):2007, 18-22. Discusses the importance of teamwork in health care and describes the TeamSTEPPS™ initiative, which is a resource for training health care providers in better teamwork practices. The program was developed jointly by AHRQ and the Department of Defense. (AHRQ 08-R001)

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)

Using Patient Safety Indicators to Estimate the Impact of Potential Adverse Events on Outcomes. P. Rivard, S. Luther, C. Christiansen, et al., Medical Care Research and Review 65(1): February 2008, 67-87. Estimates the impact of potentially preventable patient safety events as identified by the AHRQ Patient Safety Indicators on patient outcomes, mortality, length of stay, and cost. (AHRQ 08-R046)

AHRQ's Morbidity and Mortality Rounds on the Web AHRQ's WebM&M is the online journal and forum on patient safety and health care quality. The site features expert analysis of medical errors reported anonymously by users, interactive learning modules on patient safety, and perspectives on safety. CME and CEU credits are available. To learn more, visit www.webmm.ahrq.gov.

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.

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. (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 inch, 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)

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