Improving Patient Safety in Hospitals
10 Patient Safety Tips for Hospitals, http://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/.
Medical errors (or adverse events) can occur at many points in the health care system, particularly in hospitals. These tips for hospitals are from studies by the Agency for Healthcare Research and Quality (AHRQ), which has funded more than 100 patient safety projects since 2001. Hospitals can put many findings from AHRQ research into practice in by following these 10 practical tips.
2010 National Patient Safety Goals Critical Access Hospital Program
The purpose of The Joint Commission National Patient Safety Goals Critical Access Hospital Program is to improve patient safety in critical access hospitals by focusing on specific goals. This Web site contains a link to the latest goals, which include improvements emanating from the Standards Improvement Initiative. In addition, it has information regarding the new numbering system and minor language changes for consistency.
2010 National Patient Safety Goals Hospital Program
The purpose of The Joint Commission National Patient Safety Goals Hospital Program is to improve patient safety in hospitals by focusing on specific goals. This Web site contains a link to the latest goals, which include improvements emanating from the Standards Improvement Initiative. In addition, it has information regarding the new numbering system and minor language changes for consistency.
30 Safe Practices for Better Health Care Fact Sheet
This fact sheet is featured on AHRQ's Health Care Innovations Exchange Web site. The National Quality Forum has identified 30 safe practices that evidence shows can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all health care settings to reduce the risk of harm to patients. This tool also provides background information about the National Quality Forum, as well as links to a report providing more detailed information about the 30 Safe Practices.
AHRQ Health Care Innovations Exchange
AHRQ's Health Care Innovations Exchange is a comprehensive program designed to accelerate the development and adoption of innovations in health care delivery. This program supports the Agency's mission to improve the safety, effectiveness, patient centeredness, timeliness, efficiency, and equity of care. It emphasizes reducing disparities in health care and health among racial, ethnic, and socioeconomic groups. The Innovations Exchange has the following components:
AHRQ Medical Errors and Patient Safety, http://www.ahrq.gov/qual/patientsafetyix.htm
The AHRQ Medical Errors and Patient Safety Web site provides links to various resources and tools for promoting patient safety in the following categories:
AHRQ Patient Safety Network
AHRQ Patient Safety Network (PSNet) is a national 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 ("What's New"), and a vast set of carefully annotated links to important research and other information on patient safety ("The Collection"). Supported by a robust patient safety taxonomy and Web architecture, PSNet provides searching and browsing capability and allows users to customize the site around their interests (My PSNet). It also is tightly coupled with AHRQ's WebM&M, the popular monthly journal that features user-submitted cases of medical errors, expert commentaries, and perspectives on patient safety.
Becoming a High Reliability Organization, http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/hroadvice/index.html.
This AHRQ document is written for hospital leaders interested in providing patients safer and higher quality care. It presents the thoughts, successes, and failures of hospital leaders who have used concepts of high reliability to make patient care better. High reliability concepts are tools that a growing number of hospitals use to help achieve their safety, quality, and efficiency goals. Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high reliability thinking.
CAHPS® Hospital Survey
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program is a multiyear AHRQ initiative to support the assessment of consumers' experiences with health care. This Web site provides information on the CAHPS Hospital Survey (H-CAHPS), including the questionnaire and administration guidelines, as well as reporting and benchmarking data.
CAHPS® Improvement Guide
The extensive and growing use of CAHPS® (Consumer Assessment of Healthcare Providers and Systems) surveys to assess the quality of health plans, medical groups, and other organizations has created a demand for practical strategies that organizations can use to improve patients' experiences with care. This guide is designed to help meet this need. It is aimed at executives, managers, physicians, and other staff responsible for measuring performance and improving the quality of services provided by health plans, medical groups, and individual physicians. Over time, this guide will be updated to include new improvement interventions and offer additional resources.
Chasing Zero: Winning the War on Health Care Harm
A near-fatal medical error almost cost the lives of twins born to actor Dennis Quaid and his wife. This real-life event inspires a new patient education documentary featuring the Quaid family's personal ordeal, along with stories of other families who faced medical errors. It also features experts who are leading efforts to help health care providers reduce medical errors and improve patient safety outcomes.
The Commonwealth Fund
The Commonwealth Fund is a private foundation that aims to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency. The organization focuses on society's most vulnerable populations, including low-income people, uninsured people, minority groups, young children, and older adults. The Commonwealth Fund provides information on a variety of health care topics, as well as free publications and innovations and tools for improving health care.
Consumers Advancing Patient Safety
Consumers Advancing Patient Safety (CAPS) is a consumer-led nonprofit organization aimed at providing a collective voice for individuals, families, and healers who want to prevent harm in health care encounters through partnership and collaboration. CAPS features a transitions toolkit (available at http://www.patientsafety.org/page/transtoolkit/) titled "Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient."
Department of Defense Patient Safety Program
The Department of Defense Patient Safety Program is a comprehensive program designed to establish a culture of patient safety and quality within the Military Health System (MHS). The program encourages a systems approach to create a safer patient environment; engages MHS leadership; promotes collaboration across all three services; and fosters trust, transparency, teamwork, and communication.
Institute for Healthcare Improvement
IHI is a reliable source of energy, knowledge, and support for an ongoing campaign to improve health care worldwide. IHI helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.
Institute for Safe Medication Practices
The Institute for Safe Medication Practices offers a wide variety of free educational materials and services on their Web site:
- Special Medication Hazard Alerts.
- Searchable information on a wide variety of medication safety topics.
- Answers to frequently asked questions about medication safety.
- FDA Patient Safety Videos.
- Pathways for medication safety tools.
- White papers on bar-coding technology and electronic prescribing.
- A monitored message board to share questions, answers, and ideas.
Joint Commission: Patient Safety
The Patient Safety pages on the Joint Commission Web site offer information on patient safety-related standards, the National Patient Safety Goals, the Speak Up™ initiatives (a national program urging patients to become active participants on their health care team), and other resources.
Minnesota Alliance for Patient Safety
The Minnesota Alliance for Patient Safety (MAPS) is a partnership among the Minnesota Hospital Association, Minnesota Medical Association, Minnesota Department of Health, and more than 50 other public and private health care organizations working together to improve patient safety.
National Center for Patient Safety
The National Center for Patient Safety (NCPS) was established in 1999 to develop and nurture a culture of safety throughout the Department of Veterans Affairs. The primary intended audience for the public Web site is health care professionals and health care administrators.
National Patient Safety Foundation®
The National Patient Safety Foundation® has been pursuing one mission since its founding in 1997: to improve the safety of the health care system for the patients and families it serves. NPSF is dedicated to uniting disciplines and organizations across the continuum of care, championing a collaborative, inclusive, multistakeholder approach.
National Quality Forum
The National Quality Forum is a nonprofit organization that aims to improve the quality of health care for all Americans through fulfillment of its three-part mission:
Partnering With Patients To Create Safe Care, audio available in MP3 format at http://webmedia.unmc.edu/nursing/grants/jcuddiga/ihi2008/media/sIH08136.htm
Partnering With Patients To Create Safe Care is a presentation from the IHI National Forum by representatives at the Dana-Farber Cancer Institute. The presentation highlights Dana-Farber's journey in family-centered care and the steps needed to advance patient and family participation in safety and quality initiatives.
Patient Safety in Small Rural Hospitals
In July 2005, AHRQ awarded the University of Nebraska Medical Center a 2-year Partnerships in Implementing Patient Safety (PIPS) grant. The purpose of this project was to implement the patient safety practices of voluntary medication error reporting and organizational learning to improve the safety of medication use in small rural hospitals. This Web site provides a variety of patient safety tools that can be used with the AHRQ Hospital Survey on Patient Safety Culture.
Pennsylvania Patient Safety Authority
The Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in various health care settings. The Web site features current patient safety articles and highlights patient safety initiatives and tools. Users can browse by care setting, event (e.g., falls, medication errors), discipline, audience, and patient safety focus.
Premier Safety Institute®
The Premier Safety Institute provides safety resources and tools to promote a safe health care delivery environment for patients, workers, and their communities.
Transforming Hospitals: Designing for Safety and Quality
This DVD is featured on AHRQ's Health Care Innovations Exchange Web site. It reviews the case for evidence-based hospital design and describes how it increases patient and staff satisfaction and safety, quality of care, and employee retention, which results in a positive return on investment.
WHO Collaborating Centre for Patient Safety Solutions
The Joint Commission, Joint Commission International, and World Health Organization host the Centre for Patient Safety Solutions. This Web site provides information about nine solutions for improving patient safety approved by the International Steering Committee. Areas covered by the solutions include: (1) Look-Alike, Sound-Alike Medication Names, (2) Patient Identification, (3) Communication During Patient Hand-Overs, (4) Performance of Correct Procedure at Correct Body Site, (5) Control of Concentrated Electrolyte Solutions, (6) Assuring Medication Accuracy at Transitions in Care, (7) Avoiding Catheter and Tubing Misconnections, (8) Single Use of Injection Devices, and (9) Improved Hand Hygiene To Prevent Health Care-Associated Infection.
Why Not the Best?
Why Not the Best is a health care quality improvement resource from the Commonwealth Fund. In this resource, health care organizations share successful strategies and tools to create safe, reliable health care processes and deliver high-quality care to patients. Case studies and tools are linked to performance measures for particular conditions or areas of care.