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)
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)
Choosing a Patient Safety Organization: Tips for Hospitals and Health Care Providers. Agency for Healthcare Research and Quality, August 2012, 2 pp. Explains the role of patient safety organizations (PSOs) in collecting and analyzing clinical data to develop insights into the underlying causes of patient safety events. Offers tips to help hospitals and health care providers choose and work with a PSO. (AHRQ 12-0078)
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)
Despite 2007 Law Requiring FDA Hotline to Be Included in Print Drug Ads, Reporting of Adverse Events by Consumers Still Low. D. Du, J. Goldsmith, K. Aikin, et al., Health Affairs, May 2012; 31(5):1022-1029. Describes adverse event reports about 123 drugs that came from patients before and after enactment of the requirement to print the FDA hotline number in advertisements and estimates the impact of that requirement using model simulations. (AHRQ 12-R085)
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)
How Event Reporting by U.S. Hospitals Has Changed From 2005 to 2009. D. Farley, A. Haviland, A. Haas, et al., BMJ Quality and Safety, January 2012; 21(1):70-77. Examines the results of the Adverse Event Reporting System 2009 Survey of a sample of non-Federal U.S. hospitals and compares the results with those from the 2005 version of the same survey. (AHRQ 12-R047)
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)
Improving Patient Safety in Long-Term Care Facilities: Training Modules. Agency for Healthcare Research and Quality, June 2012. Intended for use by nursing homes and other long-term care facilities to train nurses, nursing assistants, and other staff in detecting changes in a resident's condition, communicating changes, and falls prevention and management.
Printed copies of the Instructor Guide and student modules can be ordered as a set or separately from the AHRQ Publications Clearinghouse. Single copies free; charges may apply for additional quantities and for shipping to addresses outside of the United States. To order, send an email to the AHRQ Publications Clearinghouse at AHRQPubs@ahrq.hhs.gov or call 1-800-358-9295. Be sure to specify the AHRQ Publication number.
Instructor Guide. Covers all three modules, including suggested slides and pre- and post-tests to gauge the student's knowledge level before and after training. (AHRQ 12-0001-1)
Instructor Set. Includes instructor guide and one copy each of the three student workbooks. (AHRQ 12-0001)
Module 1. Detecting Change in a Resident's Condition: Student Workbook (AHRQ 12-0001-2)
Module 2. Communicating Change in a Resident's Condition: Student Workbook (AHRQ 12-0001-3)
Module 3. Falls Prevention and Management: Student Workbook (AHRQ 12-0001-4)
Student Workbook Set. Includes one copy each of the three student workbooks. (AHRQ 12-0001-5)
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)
Medical Office Survey on Patient Safety Culture: 2012 User Comparative Database Report. Agency for Healthcare Research and Quality, May 2012, 66 pp. Provides data from more than 900 medical offices and nearly 24,000 medical office staff respondents who completed the survey to measure the culture of patient safety in medical offices from the perspectives of providers and staff. (AHRQ 12-0052)
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Agency for Healthcare Research and Quality, December 2011, 95 pp. Provides step-by-step instructions on ways to improve a hospital's medication reconciliation process, including a systematic methodology for critically reviewing and improving medication reconciliation processes. Includes a work plan to help apply the steps outlined in the toolkit and document progress. (AHRQ 11(12)-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).
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.
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)
Progress on a National Patient Safety Imperative to Eliminate CLABSI. C. Clancy, American Journal of Medical Quality, March 2012; 27(2):170-171. Discusses the implementation and results of the AHRQ-supported Comprehensive Unit-based Safety Program (CUSP) to reduce central line-associated bloodstream infections (CLABSI). (AHRQ 12-R068)
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)
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)
System-Related Interventions to Reduce Diagnostic Errors: A Narrative Review. H. Singh, M. Graber, S. Kissam, et al., BMJ Quality and Safety, February 2012; 21(2):160-170. Reviews the recent literature on diagnostic errors and identifies interventions that address system-related factors that contribute directly to diagnostic errors. (AHRQ 12-R052)
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)
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)
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 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)
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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