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Medical Errors & Patient Safety

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The very critical issues of medical errors and patient safety have received a great deal of attention. In November 1999, the Institute of Medicine (IOM) released a report estimating that as many as 98,000 patients die as the result of medical errors in hospitals each year.

A major Federal initiative has been launched to reduce medical errors and improve patient safety in federally funded health care programs, and by example and partnership, in the private sector.

Online Journals and Primers

AHRQ PSNet: Patient Safety Network
Web M&M: Morbidity & Mortality Rounds Online

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Tools & Resources

Tips for Consumers & Patients

Five Steps to Safer Health Care
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
20 Tips to Help Prevent Medical Errors in Children
AHRQ's Efforts to Prevent and Reduce Health Care-Associated Infections
Be Prepared for Medical Appointments
Blood Thinner Pills: Using Them Safely
Watch:
     Video Navigating the Health Care Video Advice Columns from Dr. Clancy
     Video Staying Active and Healthy with Blood Thinners (17.6 MB) (Transcript)
It's Your Health: Use Your Medications Safely
Taking Care of Myself: A Guide for When I Leave the Hospital
Ways You Can Help Your Family Prevent Medical Errors!
Your Guide to Preventing and Treating Blood Clots

Background

Advancing Patient Safety: A Decade of Evidence, Design, and Implementation
AHRQ's 2009 Funded Projects to Prevent Health Care-Associated Infections
AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk: Interim Report to the Senate
Ending Health Care-Associated Infections
To Err is Human: Building a Safer Health System: Institute of Medicine report Exit Disclaimer
Health Care-Associated Infections: Tools & Resources
Improving Patient Safety Through Simulation Research
Methodological Shortcomings and Estimates of Adverse Events: Technical Review
National Survey on Consumer Experiences With Patient Safety and Quality
Patient Safety: Achieving a New Standard for Care: Institute of Medicine report on health care data standards Exit Disclaimer
Patient Safety and Health Information Technology E-newsletter Archives
Patient Safety Research Highlights: Program Brief
Reducing Medical Errors in Health Care: Fact Sheet
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety: Institute of Medicine report Exit Disclaimer
Safe Practices for Better Healthcare: Summary: National Quality Forum Consensus Report
Web Chat Transcript: Patient Safety Research
Web M&M: Fact Sheet

Communication & Teamwork

Is Our Pharmacy Meeting Patients' Needs?
Medical Teamwork and Patient Safety: The Evidence-based Relation
Strategies to Improve Communication Between Pharmacy Staff and Patients
TeamSTEPPS™: National Implementation (Web Site)
TeamSTEPPS™ Tools

Design & Working Conditions

AHRQ Resources on System Design
The Effect of Health Care Working Conditions on Patient Safety: Evidence Report
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety: Institute of Medicine report Exit Disclaimer
The Hospital Built Environment: What Role Might Funders of Health Services Research Play?
Transforming Hospitals: Designing for Safety and Quality
   DVD Available

Implementation & Transformation

10 Patient Safety Tips for Hospitals
30 Safe Practices for Better Health Care
Advances in Patient Safety: New Directions and Alternative Approaches
Advances in Patient Safety: From Research to Implementation
AHRQ Resources on System Design
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders
Closing the Quality Gap: Quality Improvement Strategies
Closing the Quality Gap: Diabetes Care Strategies
Closing the Quality Gap: Hypertension Care Strategies
Consumer Financial Incentives: A Decision Guide for Purchasers
Developing a Community-Based Patient Safety Advisory Council
Mistake-Proofing the Design of Health Care Processes
Partnerships in Implementing Patient Safety (PIPS)Updated
   Patient Safety Tools: Improving Safety at the Point of Care
Patient Safety Improvement Corps: 2007-08 State Organizations
   DVD for Institutional Training
Patient Safety Challenge Grants: Translating Research Into Practice
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Priority Areas for National Action: Transforming Health Care Quality
Purchaser-Provider Synergies
Reducing Errors in Health Care
Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs
Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care
Taking Care of Myself: A Guide for When I Leave the Hospital
Toolkit for Redesign in Health Care

Patient Safety Culture Surveys

Surveys on Patient Safety Culture
   Hospital Survey on Patient Safety Culture
   Hospital Comparative Database Submission Information
   2010 Comparative Database Report
   2009 Comparative Database Report
   2008 Comparative Database Report
   2007 Comparative Database Report
   Nursing Home Survey on Patient Safety Culture
   Medical Office Survey on Patient Safety Culture

Patient Safety Organizations (PSOs)

Patient Safety Organizations: Web Site
Patient Safety and Quality Improvement Act of 2005

Patient Safety Research & Funding Opportunities

Advances in Patient Safety: From Research to Implementation
Ambulatory Safety and Quality Program: Health IT Portfolio
Funding Opportunities
   Active: Requests for Applications, Program Announcements, Contracts
   Archived: Grants and Contracts
Medical Liability & Patient Safety Initiative

Tools & Techniques

AHRQ Patient Safety Tools and Resources
Central Line Insertion Care Team Checklist
Designing Consumer Reporting Systems for Patient Safety Events
Pharmacy Health Literacy Center
   Automated Telephone Reminders
   How to Create a Pill Card
Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement
Problems and Prevention: Chest Tube Insertion
TeamSTEPPS™ Tools
Tools, Methods, and Techniques for Improving Patient Safety

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Conferences & Workshops

AHRQ's Quality Challenge Summit (Video)
Agenda for Research in Ambulatory Patient Safety: Conference Synthesis
Making the Health Care System Safer: Second Annual Patient Safety Research Conference
Making the Health Care System Safer: Third Annual Patient Safety Research Conference
Partnerships in Implementing Patient Safety (Technical Assistance)
Triggers and Targeted Injury Detection Systems (TIDS): Expert Panel Meeting

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Speeches & Statements


Date Title
12/3/07 Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules: Carolyn Clancy, M.D.
9/27/06 Remaking American Medicine: Carolyn Clancy, M.D.
9/25/06 The Culture of Safety: Carolyn Clancy, M.D.
10/25/05 Health Information Technology, Quality of Care, and Evidence-based Medicine: An Interlinked Triad: Carolyn Clancy, M.D.
9/9/05 Health Information Technology and the "Quality Movement": Carolyn Clancy, M.D.
6/8/05 Quality Is the Goal for Patient Safety and Health IT: Carolyn Clancy, M.D.

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Congressional Hearings


Date Title
4/1/09 Testimony on Reducing Health Care-Associated Infections: Carolyn Clancy, M.D.
3/5/08 Testimony on Health Issues and Opportunities at AHRQ: Carolyn Clancy, M.D.
6/9/05 Testimony on Patient Safety Activities at HHS: Carolyn Clancy, M.D.
3/19/04 Testimony on Health Care Quality Initiatives: Carolyn Clancy, M.D.
6/11/03 Testimony on Patient Safety: Carolyn Clancy, M.D.

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AHRQ Advancing Excellence in Health Care