Other Patient & Consumer Resources

• AHRQ Quality and Patient Safety
• National Survey on Consumer Experiences With Patient Safety and Qualit

Clinicians & Providers

• A Critical Analysis of Quality Improvement Strategies
• AHRQ Quality and Patient Safety
• Americans as Health Care Consumers
• Bundled Payment: Effects on Health Care Spending and Quality
• Care Coordination Measures Atlas
• Care Coordination, Quality Improvement
• Case Studies from the Quality Improvement Support System
• EHC Program Inside Track Newsletter
• Evaluation of the U.S. Preventive Services Task Force Recommendations
• Improving Quality of Care for People With Depression
• Medication Adherence Interventions: Comparative Effectiveness
• Model Public Report Elements: A Sampler
• Patient Safety and Quality
• Private Performance Feedback Reporting for Physicians
• Public Reporting as a Quality Improvement Strategy
• Quality Improvement Interventions to Address Health Disparities
• Quality Improvement Interventions to Address Health Disparities
• Quality Improvement Measurement of Outcomes for People With Disabilities
• Quality of Care
• Technical Review, No. 9: Closing the Quality Gap Vol. 1: Series Overvi
• Technical Review, No. 9: Closing the Quality Gap Vol. 3: Hypertension
• Technical Review, No. 9: Closing the Quality Gap Vol. 4: Antibiotic Pr
• Technical Review, No. 9: Closing the Quality Gap Vol. 5: Asthma Care
• The Patient-Centered Medical Home
• Women With Diabetes: Quality of Health Care, 2004-2005
• Women at High Risk for Diabetes: Access and Quality of Health Care, 2003-2006

Hospital & Health System Resources

• AHRQ Quality and Patient Safety
• Americans as Health Care Consumers
• Care Coordination Measures Atlas
• Case Studies from the Quality Improvement Support System
• Evaluation of the U.S. Preventive Services Task Force Recommendations
• Model Public Report Elements: A Sampler
• Patient Safety and Quality
• Private Performance Feedback Reporting for Physicians
• Quality of Care
• Team Check-up Tool
• Transforming Hospitals
• Women at High Risk for Diabetes: Access and Quality of Health Care, 2003-2006

Policymaker Resources

• AHRQ Quality and Patient Safety
• Evaluation of the U.S. Preventive Services Task Force Recommendations
• Improving Quality of Care for People With Depression
• Quality of Care
• Women With Diabetes: Quality of Health Care, 2004-2005

Fact Sheets

September 1 2012 20120901

A Critical Analysis of Quality Improvement Strategies

September 1 2012 20120901

Improving Quality of Care for People With Depression

Full Research Reports

November 1 2012 20121101

Private Performance Feedback Reporting for Physicians

September 1 2012 20120901

Evaluation of the U.S. Preventive Services Task Force Recommendations

September 1 2012 20120901

Model Public Report Elements: A Sampler

September 1 2012 20120901

Transforming Hospitals

September 1 2012 20120901

Women With Diabetes: Quality of Health Care, 2004-2005

September 1 2012 20120901

Women at High Risk for Diabetes: Access and Quality of Health Care, 2003-2006

Other Research & Data

• AHRQ Quality and Patient Safety
• AHRQ initiative encourages better two-way communication between clinicians and patients
• AHRQ's clinical care tools help clinicians ensure better and safer care
• Bundled Payment: Effects on Health Care Spending and Quality
• Care Coordination, Quality Improvement
• Communications between patients with HIV and their providers differ along racial and substance use lines
• National Survey on Consumer Experiences With Patient Safety and Qualit
• Public Reporting as a Quality Improvement Strategy
• Quality Improvement Interventions to Address Health Disparities
• Quality Improvement Measurement of Outcomes for People With Disabilities
• Quality of Care
• Re-engineered discharge project dramatically reduces return trips to the hospital
• Simpler drug warning labels are easier to understand
• Simplified drug warnings improve patients' understanding of what to do or avoid when given a particular prescription
• Technical Review, No. 9: Closing the Quality Gap Vol. 1: Series Overvi
• Technical Review, No. 9: Closing the Quality Gap Vol. 3: Hypertension
• Technical Review, No. 9: Closing the Quality Gap Vol. 4: Antibiotic Pr
• Technical Review, No. 9: Closing the Quality Gap Vol. 5: Asthma Care
• Transparency enhances physician communication with patients

Press Releases

September 10 2012 20120910

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent

Other News & Events

• No consistent association found between volume or quality and outcomes of complex surgeries for cancer
• 1 in 10 computer-generated prescriptions include at least one error
• A "diabetes dashboard" screen helps clinicians quickly and accurately access patient data needed for quality diabetes care
• A few preoperative factors can be used to predict inpatient deaths following surgery
• A five-point checklist can help public report sponsors avoid misclassifying the performance of health care providers
• A hospital's ability to rescue patients from complications after high-risk surgery determines mortality rates
• A large proportion of hospitalized children receive numerous medications during their hospitalization
• AHRQ awards $34 million to expand fight against healthcare-associated infections
• AHRQ initiative encourages better two-way communication between clinicians and patients
• AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung
• AHRQ report examines the effect of quality improvement interventions on palliative care
• AHRQ report finds teamwork and followup as strengths of medical offices but work pressure and pace are problematic
• AHRQ safety project reduces bloodstream infections by 40 percent
• AHRQ toolkit helps to prevent hospital-acquired pressure ulcers
• AHRQ's clinical care tools help clinicians ensure better and safer care
• AHRQ-funded medical liability and patient safety initiative shows promise for reducing patient harm, lawsuits, and costs
• Adequate financial bonuses and peer support motivate providers to adhere to evidence-based treatment guidelines
• Adjusting hospital admissions by day can help with overcrowding in children's hospitals
• Administration of antimicrobials just prior to surgery reduces the risk of surgical site infections
• Adults with individual and employment-related health insurance report similar, often good, access to care
• Adverse drug event surveillance tailored to hospitalized children
• Adverse events occurring during pediatric sedation are recorded in charts but not always reported
• An automated phone response system can help track adverse drug events in primary care patients
• Anemia is common among nursing home residents and affects their physical functioning
• Annual quality and disparities reports include data on health care-associated infections, obesity, and health insurance
• Assessment of hospital computerized physician order entry systems finds many medication errors are missed
• Asthma project helps resident physicians improve care for minority patients
• Automated quality measures can be used to improve asthma care
• Automated screening of patient electronic medical records is only the first step to identifying a medication problem
• Benefits and risks of helicopter transport for trauma patients investigated
• Better hospital quality of care for the elderly is associated with lower mortality after discharge
• Black patients are negatively affected by clinicians' attitudes about race
• Blacks treated at community health centers are less likely than Hispanics or whites to have controlled blood pressure
• Blacks with lung cancer have higher mortality rates than whites
• California nurse staffing mandate did not reduce nursing workforce skill levels
• Care setting affects likelihood that children with persistent asthma will receive inhaled steroids
• Certain antibiotics increase the risk of treatment failure in children with MRSA-related skin and soft-tissue infections
• Certain factors can help prepare families to bring infants home from neonatal intensive care units
• Certain factors increase risk of medication errors in the neonatal intensive care unit (NICU)
• Cesarean delivery rates may not be a useful measure of obstetric quality
• Challenges abundant for practices that use fax referrals to smoking cessation quitlines
• Children with a medical home more likely to receive health screenings and advice
• Chronic Care Model linked to exercise discussions during primary care office visits for diabetes
• Clinical informatics monitoring tool helps reduce adverse drug events in nursing home settings
• Clostridium difficile infection rate has risen among hospitalized children since late 1990s
• Colony-stimulating factor is effective in reducing infection for elderly patients with non-Hodgkin's lymphoma on chemotherapy
• Combining strategies cuts hospitals’ healthcare-associated infection rates
• Communications between patients with HIV and their providers differ along racial and substance use lines
• Community health center collaboratives improve care quality but have little impact on disparities
• Complications and in-hospital deaths more frequent among patients who undergo anterior rather than posterior spine fusion
• Complications increase mortality of trauma patients
• Computerized decisionmaking systems improve physician prescribing for long-term-care residents
• Consider local health care systems when designing services for the uninsured
• Consumers choose "high-value" health care providers when given combined cost and quality information
• Contact isolation of new patients reduces adherence to process-of-care quality measures for pneumonia
• Criteria used to identify "drugs to avoid" in the elderly are not very accurate
• Delays in reporting medical errors at Japanese hospital nearly triple that of United States hospital
• Detailed, up-to-date medication lists help prevent errors
• Disparities Report highlights health care challenges for minorities, underscores importance of Affordable Care Act
• Dissemination and implementation of clinical trial results are needed to encourage recommended practices
• Distance-based training in spirometry use increases the quality of asthma diagnosis
• Drug discontinuation effects are not limited to psychoactive drugs, but may be important for cardiovascular drugs as well
• Drug monitoring may be improved by the use of health information technology and clinical pharmacists
• Dual Veterans Administration/Medicare users are not hospitalized more for ambulatory care sensitive conditions
• Duplicate medication order errors increase after computerized provider order entry is implemented
• Elderly blacks less likely than elderly whites to receive a depression diagnosis or treatment
• Elderly lung cancer patients experience more adverse events during chemotherapy than younger patients
• Electronic health record decision support improves the care of children with ADHD
• Electronic health records can help detect diagnostic errors in primary care
• Electronic health records improve nursing care, coordination, and patient safety
• Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
• Electronic medical records reduce negative outcomes and related costs after patient safety events occur
• Electronic order sets can help treatment conform to guidelines for antibiotic use after surgery
• Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
• Enrollment in Medicare Advantage managed care plans reduces racial/ethnic disparities in primary care quality in some States
• Evaluation of the U.S. Preventive Services Task Force Recommendations
• Evidence-based strategies substantially reduce the incidence of ventilator-associated pneumonia in ICUs
• Expert workshop discusses disparities in health care quality and role of health IT in underresourced settings
• FACE cards have a small positive effect on hospital patients' ability to identify their physicians
• Failure to order and follow up medical tests are leading causes of diagnostic errors
• Fecal occult blood tests and followup need to be better targeted to healthy older adults
• Financial performance has modest effect on nursing home quality improvement
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• For 1 in 10 Medicaid patients, it's back to the hospital in a month
• For-profit dialysis chains have higher mortality rates than non-profit dialysis chain
• Fragmentation of care for complex diabetes patients may be associated with greater use of the emergency department
• Giving consumers easy-to-understand information on health care quality and costs boosts the choice of high-value care
• Going smooth can help relieve weekday crowding at children's hospitals
• Greater use of preventive measures needed for hospitalized patients with suspected venous thromboembolism
• Guideline familiarity does not equal guideline adherence
• Having a usual source of care as well as insurance reduces unmet health needs
• Having a usual source of care promotes preventive health counseling for children
• Health Care Quality Gaps and Disparities Persist in Every State
• Health care quality still improving slowly, but disparities and gaps in access to care persist
• Health information technology improves care and saves lives
• Health insurance is necessary but not sufficient for children's access to care
• Health plans vary widely in the prescribing of antibiotics
• High performance on quality measures linked to financial benefits for nursing homes
• High-volume hospitals have low rates of adverse events for high-risk surgeries
• Higher nurse-patient ratios result in societal cost benefits for some hospital areas
• Hospital Compare data may not help surgical patients find hospitals with better outcomes
• Hospital boards adopt practices to enhance oversight on quality of care
• Hospital deaths from heart failure cut by half over 7 years
• Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data
• Hospital risk managers more likely than physicians to recommend error disclosure, but less likely to apologize
• Hospital volume does not predict mortality for patients undergoing lung cancer surgery
• Hospital-acquired infections dramatically increase trauma patients' risk of in-hospital death and hospital stay
• Hospitalists modestly improve quality of care
• Hospitals face dilemmas about disclosure of large-scale adverse events
• Hospitals vary greatly in the quality of their trauma care
• Hospitals with a high volume of sepsis admissions have lowest mortality rates
• Hospitals with a teamwork culture have better patient safety climates
• Hydroxychloroquine still underused by patients with lupus, but use more likely if treated by rheumatologists
• ICUs in Michigan sustain zero bloodstream infections for up to 2 years
• Immersive simulation training for CPR shows no benefit over standard training
• Improvements are needed to better measure mental health care quality
• Improving quality of care for falls and urinary incontinence also improves quality of life in elderly patients
• Infrequent physician use of implantable cardioverter-defibrillators presents potential risks to patient safety
• Interdisciplinary team training with in-situ simulation helps reduce adverse events in obstetric patients
• Introduction of hospice services by nursing homes does not significantly affect nursing assistant staffing
• Label changes, manufacturer's warning letter did not reduce use of propofol for conscious sedation in children
• Laboratory monitoring of high-risk medications varies greatly
• Landmark initiative to reduce healthcare-associated infections cuts deaths among Medicare patients in Michigan ICUs
• Leapfrog survey may not accurately report use of safe practices in trauma centers
• Leg compression devices are not a significant factor in in-hospital falls
• Length of stays in emergency departments varies considerably
• Less than half of pharmacy computer systems studied correctly identified drug-drug interactions
• Liver transplant patients who taper off or do not take corticosteroids after transplantation have better quality of life
• Longer use of electronic health records is not linked to improved quality of care
• Low- and middle-income children with public and private insurance have similar rates of unmet health care needs
• Lower complications are seen after laparoscopic kidney removal
• Lower flu vaccination rates for black nursing home residents a cause for concern
• Lower mortality rates after surgery at high-volume hospitals due to fewer complications and other factors
• MRSA can spread slowly but surely in households
• Making nursing home quality reports public leads to improved posthospitalization care
• Many Federal drug risk alerts fail to achieve the recommended changes in prescribing
• Market competition has only marginal effect on hospital performance for heart failure
• Measuring quality of care for middle ear infection has many pitfalls
• Medicaid drug restrictions may lead to adverse events for psychiatric patients
• Medicaid pay-for-performance program in Massachusetts fails to improve quality during first-year
• Medical home for children and youth improves delivery of preventive services without raising expenditures
• Medical residents can use quality improvement methods to promote obesity screening
• Medical students, interns, and residents need training to disclose medical errors
• Medicare Advantage enrollees are admitted to hospitals with higher mortality rates than Medicare fee-for-service enrollees
• Medicare managed care reduced preventable hospitalizations in 2004 more than fee-for-service Medicare
• Medication changes are not always documented properly in physician notes or the electronic medical record
• Medication review technique may help identify drug-related problems in the elderly
• Medication safety indicators can guide improvement in primary care drug selection, dosing, and monitoring
• Mental demands of pediatric hospital pharmacy staff have varying effects on likelihood of medication errors and adverse events
• Minority patients are less likely to have surgery performed by high-volume surgeons and hospitals
• Minority-serving hospitals have problems with quality of care and patient satisfaction
• More safeguards needed to prevent adverse drug events caused by medication administration errors
• Most acute-care hospitals follow national guidelines for the prevention and treatment of MRSA infections
• Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
• Nearly 1 in 10 outpatient computerized prescriptions contains errors
• Nearly one-third of emergency department visits involve nonideal care events
• New AHRQ tool assesses patient safety culture in pharmacies
• New study finds e-prescribing is safe and efficient, but barriers remain
• New tool developed to reduce risks to patients during clinical handoffs
• New tools help improve patient safety for those with limited English
• No greater risk or mortality observed for endoscopic vein harvesting for coronary bypass surgery
• Nonphysicians can be trained to assess residents' competence in catheter insertion
• Nurse-facilitated guided care for elders and their caregivers leads to improved perceptions of quality of care
• Nurses in hospital units with a higher proportion of short-term patients take longer to respond to patient call lights
• Nurses with higher education levels rate themselves as having more clinical expertise and are sought out for their guidance
• Nursing home hospice patients are not receiving adequate treatment for nonpain symptoms
• Nursing home physicians and nurses struggle with communication barriers
• Nursing home studies focus on the costs of staff turnover rates and selective admission of patients
• Nursing homes more often voluntarily terminate from Medicare and Medicaid programs in States with strong quality regulations
• Nursing homes using more agency staff have lower quality of care
• One in four patients experiences revolving-door hospitalizations
• One patient safety indicator may offer a glimpse at a hospital's overall safety record
• Opioid prescriptions for treating chronic abdominal pain doubled between 1997 and 2008
• Oral chemotherapy drugs not immune to medication errors
• Outcomes of trauma patients depend heavily on whether recommended practices are followed
• Outpatient advice on pediatric medication safety is inadequate
• Overcrowding in emergency departments increases the risk of preventable medical errors
• Pain management in emergency departments has improved but can still be better
• Parents continue to weigh vaccine benefits with adverse effects when deciding to vaccinate their children
• Participation in reporting quality data can be costly for physicians and practices
• Patient outcomes are better than hospital volume for identifying high-quality bariatric surgery centers
• Patient preferences are important when making clinical decisions for those who can't, but other factors also play a role
• Patient surveys are an additional useful tool for identifying adverse events occurring during hospital stays
• Patients at small urban hospitals are more likely to suffer from pressure sores than those at small rural hospitals
• Patients hospitalized for burn injuries in New York have comparable outcomes at major burn centers
• Patients often say good things about their physicians on rate-your-doc Web sites, but are less positive about system issues
• Patients recovering in the hospital from total knee or hip replacement have increased risk of falls
• Patients who suffer strokes and are seen at designated stroke centers fare better in the short and long run
• Patients who undergo knee ligament reconstruction do better when the doctor or hospital perform it frequently
• Patients with coronary artery disease who get ongoing support from their community pharmacy may adhere better to medications
• Pay-for-performance does not improve care quality in the short term in safety-net settings
• Perceived reputation and other factors influence consumers' hospital choices
• Performance measures for gastroenterology can lead to improved accountability
• Performing cardiac catheterization and heart surgery on different hospital admissions may reduce risk of kidney damage
• Person-to-person transmission of E. coli resistant to fluoroquinolone drugs is rare among hospital patient
• Pharmacy, medical, and nurse practitioner students need more education on drug-drug interactions
• Physician champions key to successful quality improvement projects
• Physician personality factors do not seem to influence whether patients with symptoms undergo extended diagnostic evaluations
• Physician recommendations for defibrillator therapy not influenced by race or gender
• Physicians aren't confident they can recognize infections from anthrax and other bioterrorism disease threats
• Physicians can use 10 strategies to manage abnormal test result alerts in electronic health records
• Physicians in practices focused on quality improvement are less likely to be dissatisfied and stressed
• Physicians need to be better educated about FDA-approved indications for drugs and evidence for off-label drug use
• Physicians who use electronic health records more intensively are more likely to use patient registries to improve care
• Physicians' implicit racial attitudes influence prescribing of opioids for black children
• Physicians' reasons for deviating from quality guidelines are usually justified
• Pilot study finds a low level of medication errors for look-alike, sound-alike drugs prescribed for children
• Poorer patients less likely to receive specific treatment for head and neck cancer
• Prenatal screening for Group B streptococci often fails to live up to current screening and treatment guidelines
• Preventive care for patients with lupus could be improved
• Primary anterior cervical fusion has lower in-hospital complication rates and deaths than posterior cervical fusion
• Primary care coordination is more difficult for patients who see many specialists
• Primary care physicians' performance ratings depend on the makeup of their patient population
• Primary care practices can boost clinical preventive services with electronic health records and quality improvement support
• Public report cards prompt nursing homes to spend more on clinical services
• Public reporting of performance data seems to motivate and energize improvements to hospital performance
• Public reporting on quality of care has definite, if modest, effects on nursing home care improvement
• Published sources on warfarin interactions with other drugs, food, and supplements tend not to agree
• Quality improvement collaborative improves outcomes in children with inflammatory bowel disease
• Quality improvement collaborative improves outcomes in children with inflammatory bowel disease
• Quality improvement initiative successful in sustaining reduction in bloodstream infections caused by catheters
• Quality measures are not used with all patients who suffer heart attacks
• Quality of Care
• Rates of pneumonia dramatically reduced in patients on ventilators in Michigan intensive care units
• Re-engineered discharge project dramatically reduces return trips to the hospital
• Readmissions in 30 days or less account for 1 in 9 hospital admissions
• Relative inefficiency of rural critical access hospitals must be balanced against their contributions to care access and quality
• Report examines quality improvement measurement in people with disabilities
• Rescuer experience with out-of-hospital emergency intubation is often associated with improved patient survival
• Research shows health IT enables quality measurement, but obstacles remain
• Researchers develop a task list to evaluate primary care workflow
• Restricting residents' working hours decreases teaching time but improves well-being
• Rural and urban residents have similar perceptions of health care quality, despite differences in care delivery
• Rural patients with a serious form of gallstone disease are less likely than urban patients to receive treatment
• Serious complications from bariatric surgery are fewer when done by high-volume hospitals and surgeons
• Simpler drug warning labels are easier to understand
• Simplified drug warnings improve patients' understanding of what to do or avoid when given a particular prescription
• Simulating equipment failures can be useful to hone anesthesia providers' skills
• Simulation training improves insertion of central venous catheters
• Simulation training in the operating room improves competency for the entire operating room team
• Southeastern and mid-Atlantic States have highest rate of sepsis-relat
• Specific primary care strategies may improve medication safety
• Studies examine impact of drug caps and pay for performance on care costs and outcomes
• Studies examine safety of pain killers among older adults
• Study describes challenges of using electronic health record-derived measurements for quality reporting
• Study fails to find link between guideline-based emergency treatment for pediatric asthma and patient outcomes
• Study finds potentially suboptimal use of antidepressants for residents in Veterans Affairs nursing homes
• Study identifies signals that may predict infant neurological impairment
• Study provides insights into problems confronting quality improvement educational programs in rural hospitals
• Study recommends disclosure of medical mistakes that affect multiple patients
• Study suggests caution in interpreting impact of nurse staffing levels on postsurgical complication rates
• Superficial surgical site infections are a reliable measure of hospital quality
• Surgery and imaging rates for children's kidney stones are stable, but vary greatly from hospital to hospital
• Surgical infection prevention measures reduce postoperative infections when used together, but not singly
• Systems to detect adverse drug events need buy-in from leaders and staff to become part of hospital routine
• Telemedicine dermatology consultations change diagnoses and improve outcomes
• The quality of children's asthma care is affected by emergency department crowding
• The stability of a usual source of care is important to the care of low-income children
• To reduce hospital deaths, managing surgical complications may be as important as preventing them
• Transparency enhances physician communication with patients
• Trauma care costs less at hospitals with lower mortality rates
• Trauma center patients treated after hours or on weekends have no difference in mortality rates
• Trauma centers vary in screening for deep vein thrombosis
• Trauma patients are more likely to die after a major complication in high-mortality hospitals
• Treatment for blocked carotid arteries varies depending on where you live
• Trigger tools have potential to detect adverse events following outpatient surgery
• Two different tools help measure tracheal intubation adverse events and performance in pediatric intensive care units
• Types and rates of fungal infections vary among groups and treatment is often suboptimal
• Up to $500 million in Affordable Care Act funding will help health providers improve care
• Using bar-code technology with eMAR reduces medication administration and transcription errors
• Vaccines with names that look and sound alike can lead to vaccination errors
• Variations exist in cardiac arrest care provided by emergency medical personnel
• Various factors affect providers' ability to identify spoken drug names
• Volume of paid outpatient malpractice claims underscores need for greater patient safety efforts in this area
• Ways to reduce contrast-induced acute kidney injury from imaging procedures in patients with cardiovascular disease
• When health plans share physicians, they may have less incentive to improve care quality
• Whistleblowers in pharmaceutical fraud cases pursue Federal lawsuits for moral reasons, not money