Patient Safety/Medical Errors

Accidental Iatrogenic Pneumothorax in Hospitalized Patients. C. Zhan, M. Smith, D. Stryer, Medical Care 44(2): February 2006, 182-186. Assesses the risk for accidental iatrogenic pneumothorax in patients hospitalized with specific diagnoses who underwent specific procedures. (AHRQ 06-R029)

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)

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)

AHRQ WebM&M. Agency for Healthcare Research and Quality, March 2003, two-fold brochure. Describes a Web-based patient safety resource that incorporates a peer-reviewed journal. Site includes descriptions of specific cases of medical errors and patient safety problems, commentaries, a users' forum, and links to other patient safety resources. (AHRQ 03-0014)

Ambulatory Care Visits for Treating Adverse Drug Effects in the United States, 1995-2001. C. Zhan, I. Arispe, E. Kelley, et al., Joint Commission Journal on Quality and Patient Safety 31(7): July 2005, 372-378. Explores the use of existing national surveys and ICD-9-CM codes for ambulatory visits for adverse drug effects to assess national prevalence of adverse drug effects. (AHRQ 05-R067)

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)

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)

Evaluating the Patient Safety Indicators: How Well Do They Perform on Veterans Health Administration Data? A. Rosen, P. Rivard, S. Zhao, et al., Medical Care 43(9): September 2005, 873-884. Examines differences between observed and risk-adjusted Patient Safety Indicator (PSI) rates in the Veterans Health Administration (VA), compared to VA and non-VA PSI rates, and investigates the construct validity of the PSIs by examining correlations of the PSIs with other outcomes of VA hospitals. (AHRQ 06-R012)

First, Do No Harm: Reducing Pediatric Medication Errors. R. Hughes, E. Edgerton, American Journal of Nursing 105(5): May 2005, 36-42. Discusses the frequency of pediatric medication errors, the unique vulnerabilities of children, and the disproportional reliance on ambulatory care as compared to inpatient care. (AHRQ 05-R052)

Hospital Finances and Patient Safety Outcomes. W. Encinosa, D. Bernard, Inquiry 42: Spring 2005, 60-72. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events for major surgeries. (AHRQ 05-R070)

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: 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)

The Importance of Safety and Quality in Rural America. H. Burstin, M. Wakefield, The Journal of Rural Health 20(4): October 2004, 301-303. Introduction to a special issue that draws much-needed research attention to the topic of rural health care quality and attempts to stimulate appropriate redesign in rural health care systems and practices through institutional, academic, and public policy change. (AHRQ 05-R043)

Improving Patient Safety—Five Years After the IOM Report. D. Altman, C. Clancy, R. Blendon, New England Journal of Medicine 351(20): November 11, 2004, 2041-2043. Discusses the state of improving patient safety in hospitals after a 1999 report from the Institute of Medicine featured statistics about preventable medical errors. (AHRQ 05-R017)

Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory. M. Tamuz, M. Harrison, Health Services Research Part II, 41(4): August 2006, 1654-1676. Identifies the distinctive contributions of high-reliability theory and normal accident theory as frameworks for examining five patient safety practices. (AHRQ 06-R076)

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)

Keeping Our Promises: Research, Practice, and Policy Issues in Health Care Reliability; Foreword to a Special Issue of Health Services Research. J. Reinertsen, C. Clancy, Health Services Research 41(4): August 2006, 1535-1538. Introduces a special journal issue focused on an organizational approach to patient safety, including articles on research and policy issues in reliability, organizational culture, and translation of reliability theory into practice. (AHRQ 06-R074)

Medical Teamwork and Patient Safety: The Evidence-Based Relation. Agency for Healthcare Research and Quality, April 2005, 59 pp. Presents evidence to support the relation between team training and patient safety. Presents background information related to teamwork, including the nature of effective teamwork, teamwork-related knowledge, skills, and attitudes, and contextual issues surrounding teamwork. (AHRQ 05-0053)

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)

Medication Errors:Why They Happen and How They Can Be Prevented. R. Hughes, E. Ortiz, American Journal of Nursing Supplement: March 2005, 14-24. Provides an overview of what is known about errors in medication administration, barriers to implementing safer practices, and current and potential mechanisms to improve medication administration. (AHRQ 05-R044)

Nurses'Working Conditions: Implications for Infectious Disease. P. Stone, S. Clarke, J. Cimiotti, et al., Emerging Infectious Diseases 10(11): November 2004, 1984-1989. Discusses the nurse workforce, reviews research examining nursing as it relates to infectious disease, identifies gaps in the literature, and discusses potential policy options. (AHRQ 05-R006)

Organizational Silence and Hidden Threats to Patient Safety. K. Henriksen, E. Dayton, Health Services Research Part II, 41(4): August 2006, 1539-1554. Focuses on some of the less obvious factors contributing to organizational silence—a collective-level phenomenon of saying or doing very little in response to significant problems that face an organization—that can threaten patient safety. (AHRQ 06-R060)

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)

Relationship Between Performance Measurement and Accreditation: Implications for Quality of Care and Patient Safety. M. Miller, P. Pronovost, M. Donithan, et al., American Journal of Medical Quality 20(5): September/October 2005, 239-252. Examines the association between the Joint Commission on Accreditation of Healthcare Organizations accreditation scores and the AHRQ's Inpatient Quality Indicators and Patient Safety Indicators. (AHRQ 06-R005)

Sensemaking of Patient Safety Risks and Hazards. J. Battles, N. Dixon, R. Borotkanics, et al., Health Services Research Part II, 41(4): August 2006, 1555-1575. Defines patient safety sensemaking in the context of eliminating risks and hazards that are a threat to patient safety and discusses it as a conceptual framework. (AHRQ 06-R059)

Struggling to Invent High-Reliability Organizations in Health Care Settings: Insights from the Field. N. Dixon, M. Shofer, Health Services Research Part II, 41(4): August 2006, 1618-1632. Discusses an analysis of findings from an AHRQ consumer needs assessment of leaders in selected health care systems, asking questions about current implementation initiatives and perceived needs for continued implementation of patient safety initiatives. (AHRQ 06-R075)

Tracking Rates of Patient Safety Indictors Over Time: Lessons from the Veterans Administration. A. Rosen, S. Zhao, P. Rivard, et al., Medical Care 44(9): September 2006, 850-861. Provides a descriptive analysis of the incidence of Patient Safety Indicator (PSI) events from 2001 to 2004 in the Veterans Health Administration, examines trends in national PSI rates at the hospital discharge level over time, and assesses whether hospital characteristics and baseline safety-related hospital performance predict future hospital stay-related performance. (AHRQ 06-R078)

Training Health Care Professionals for Patient Safety. C. Clancy, American Journal of Medical Quality 20(5): September/October 2005, 277-279. Discusses AHRQ's goals, vision, and role in ongoing professional education and staff training to foster a new culture of patient safety. (AHRQ 06-R006)

Using Standardised Patients in an Objective Structured Clinical Examination as a Patient Safety Tool. J. Battles, S. Wilkinson, S. Lee, Quality & Safety in Health Care 13(Suppl 1):2004, i46-i50. Describes how using individuals who have been trained to portray a medical case in a consistent manner can be a powerful tool in measuring continued competence in human reliability and skill performance where such skills are a critical attribute to maintaining patient safety. (AHRQ 05-R027)

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)

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