Organizational Change
Are critical pathways worth the
money? Critical pathways are health
care management plans that specify
patient goals and the sequence and
timing of actions necessary to achieve
these goals with optimal efficiency.
More than 80 percent of hospitals in the
United States use critical pathways for at
least some of their patients. AHRQ
researchers assessed whether critical
pathways have been successful in
reducing patient length of stay and
resource utilization. They found that
most pathways reduced neither and
cautioned that further evaluation of
critical pathways is necessary before
additional resources are consumed for
this management strategy.
Project Title: Targeting Interventions to
Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer,
M.D.
Reference: Saint S, Hofer TP, Rose JS,
Kaufman SR, McMahon LF Jr. Use of
critical pathways to improve efficiency: a
cautionary tale. Am J Manag Care 2003
Nov;9(11):758-65.
Pittsburgh guidelines for health
system redesign developed
successful strategies for improving
patient safety. Fundamental changes
are needed in the health care system to
improve patient safety, but there is no
commonly accepted blueprint for
redesigning the system. AHRQ
researchers examined the Pittsburgh
Regional Healthcare Initiative
(PRHI)—a health system redesign
project that includes 44 hospitals in 12
counties in southwestern Pennsylvania,
along with major insurers, health care
purchasers, and civic leaders. Key
features in this design are linking patient
outcomes data with processes of care;
sharing that information widely; real-time
error reporting; and quick,
decentralized problem solving among
participating institutions . The study
helped develop successful strategies for
improving patient safety. Many PRHI
recommended practices and guidelines
have been disseminated regionally and
are available at http://www.prhi.org.
Project Title: Systems Approach for
Improving Region-Wide Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11926
Principal Investigator: Carl A. Sirio,
M.D.
Reference: Sirio CA., Segel KT, Keyser
DJ., et al. Pittsburgh Regional
Healthcare Initiative: a systems
approach for achieving perfect patient
care. Health Aff 2003 Sep-Oct;22(5):157-65.
Preplanning enables well-defined
courses of action and, at the same
time, effectively handles unlikely
events in the cardiac operating
room. Plans and planning behavior by
health professionals are fundamental to
patient safety, but planned actions in
health care are rarely static. Preparation
facilitates effective, expected courses of
action while accommodating real-world
contingencies and unforeseen
circumstances. An AHRQ study found
that successful cardiac surgery requires
having the right tools for the job in the
right place at the right time, even in the
face of unforeseen circumstances.
AHRQ researchers collected and
analyzed video and audio recordings of
20 surgical cases involving both
coronary artery bypass surgery and heart
valve replacement and described how
preplanning enables well-defined courses
of action and at the same time
effectively handles unlikely events in the
cardiac operating room.
Project Title: Ethnography of
Transitions in Cardiac Care
AHRQ Grant: HS12003
Research Area: WC
Principal Investigator: Paul Gorman,
M.D.
Reference: Hazlehurst B, McMullen C,
Gorman P. Getting the right tools for
the job: preparatory system
configuration and active replanning in
cardiac surgery. In: Santos E, Willett P,
editors. IEEE International Conference
on Systems, Man & Cybernetics. Vol 2.
Piscataway, New Jersey; 2003. pp. 1784-91.
Using virtual patient care units
may improve patient safety and
outcomes. Research data from health
care systems are usually complex and
present information as a snapshot in
time. This makes application difficult in
a dynamically changing health care
system. To transform complex data into
information that nurses can use, AHRQ
researchers used computational
modeling, a set of tools that allows users
to create a virtual model of a particular
system such as a patient care unit. Based
on real patient care units, they created
16 virtual units that are functionally
similar to their real counterparts in key
characteristics of the unit and patient
safety outcomes.
Project Title: The Impact of Nursing
Unit Characteristics on Outcomes
AHRQ Grant: HS11973
Research Area:WC
Principal Investigator: Joyce Verran,
M.D.
Reference: Effken JA, Brewer BB, Patil
A, Lamb GS, Verran JA, Carley KM.
Using computational modeling to
transform nursing data into actionable
information. J Biomed Inform 2003
Aug-Oct;36(4-5):351-61.
Primary care offices can be made
safer by emphasizing information
systems, promoting a culture of
quality, and improving the
environment. The Minimizing Error,
Maximizing Outcome (MEMO) Study
used a conceptual model to relate office
working conditions to quality of care, as
mediated by physician reactions.
Physician surveys assessed office
environment and organizational climate.
A chaotic office atmosphere was
strongly associated with physician stress,
a lack of quality emphasis was associated
with past errors, and a lack of emphasis
on information and communication was
associated with a higher likelihood of
future errors. AHRQ researchers found
that primary care offices could be made
safer by emphasizing information
systems, promoting a culture of quality,
and improving the environment.
Project Title: Minimizing Error,
Maximizing Outcome (MEMO): The
Physician Worklife Study II
AHRQ Grant: HS11955-03
Principal Investigator: Mark Linzer,
M.D.
Reference: Linzer M, Manwell LB,
Mundt M, Williams E, Maguire A,
McMurray J, Plane MB. Organizational
climate, stress, and error in primary
care: the MEMO Study. In: Henriksen
K, Battles JB, Marks ES, Lewin DI,
editors. Advances in Patient Safety: From
Research to Implementation. Vol. 1,
Research Findings. AHRQ Publication
No. 05-0021-1. Rockville, MD: Agency
for Healthcare Research and Quality;
Feb 2005. pp. 65-77.
Do too many distractions affect
nursing care? The acute care hospital
environment is filled with numerous
distractions. Within this environment,
professional nurses make clinical
judgments about their patients, whose
conditions may change minute by
minute. As a result, nurses constantly
organize and reorganize the priorities
and tasks of care to accommodate
patients' fluctuating status. AHRQ
researchers describe an ongoing research
study aimed at exploring the effect of
interruptions on the cognitive work of
nursing. By combining human factors
techniques and qualitative observation
of nurses in practice, researchers
produced a cognitive pathway, a unique
visual graphic that offers a perspective of
the nature of nurses' work and the effect
of interruptions and cognitive load on
omissions and errors in care.
Project Title:Work Environment:
Effects on Quality of Healthcare
Research Area: WC
AHRQ Grant: HS11983
Principal Investigator: Bradley
Evanoff, M.D., M.P.H.
Reference: Potter P, Wolf L, Boxerman
S, Grayson D, Sledge J, Dunagan C,
Evanoff B. An analysis of nurses'
cognitive work: a new perspective for
understanding medical errors. In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to Implementation.
Vol. 1, Research Findings. AHRQ
Publication No. 05-0021-1. Rockville,
MD: Agency for Healthcare Research
and Quality; Feb 2005. pp. 39-51.
*Learning-from-defects tool
enhances safety by guiding realtime
incident analysis and action
planning. AHRQ researchers
developed a systematic approach for
practitioners and administrators to
identify and explain systems that lead to
defects in patient care. Similar to root
cause analysis and for use in all settings
of care, the Learning from Defects
(LFD) tool provides a three-step process
for prompt investigation of specific
incidents of shortcomings in care. This
tool also facilitates the development of
incident-specific risk reduction
strategies. The article includes an
example copy of the tool, including a
one-page user's guide, an example of a
completed incident investigation form,
and a model case summary—outlining
major lessons learned, with
corresponding safety tips to reduce the
likelihood of the incident re-occurring.
Project Title: Intensive Care Unit
Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter
Pronovost, M.D., Ph.D.
Reference: Pronovost P, Holzmueller
CG, Martinez E, Cafeo CL, Hunt D,
Dickson C, Awad Michael, Makary
MA. A practical tool to learn from
defects in patient care. Jt Comm J Qual
Pat Saf 2006 Feb;32(2):102-8.
*Patterns of patient-, medication and
care-related factors can
foreshadow hospitalized patients'
risk of falling. Inpatient falls can lead
to avoidable patient injuries and
increased costs. However, few studies
have assessed care-related and
environmental factors associated with
both elderly and nonelderly falls in
hospitals. AHRQ researchers conducted
a case-control study of 98 adult patients
who fell while hospitalized. Patient-,
medication-, and care-related factors
that were significantly associated with an
increased risk of falling included gait or
lower extremity problems, confusion,
use of sedatives or diabetes medications,
and increased patient-to-nurse ratios.
Eighty-five percent of patients under
orders of "up only with assistance" were
not using assistance when they fell. In
addition to patient characteristics, fall
prevention programs must address
common care-related circumstances
surrounding patients' falls.
Project Title: Surveillance, Analysis,
and Interventions to Improve Patient
Safety
Research Area: R-DEMO
AHRQ Grant: HS11898
Principal Investigator: Victoria Fraser,
M.D.
Reference: Krauss MJ, Evanoff B,
Hitcho E, Ngugi KE, Dunagan WC,
Fischer I, Birge S, Johnson S,
Costantinou E, Fraser VJ. A
case-control study of patient,
medication, and care-related risk factors
for inpatient falls. J Gen Intern Med 2005 Feb;20(2):116-22.
The AIM quality improvement
process can significantly reduce
the incidence of pressure ulcers
among nursing home residents.
Quality improvement processes that
target frontline caregivers, but lack
active oversight by the administration,
have had little success in reducing the
incidence of pressure ulcers (PU) among
nursing home residents. AHRQ
researchers developed and implemented
a three-pronged approach called AIM-ability
enhancement, incentives, and
management feedback-in a 136-bed
Pennsylvania nursing home with a
history of multiple Department of
Health citations. AIM empowers
management with the resources to:
directly oversee and enforce skin care
education among staff; provide staff
with monetary incentives for reaching
predetermined PU-related goals; and
issue consistent, real-time feedback to
employees. Over a 12-week
intervention period, AIM reduced the
incidence of PUs (at all stages) among
the home's residents from 28 to 3
percent. Researchers conclude that
quality improvement processes that
empower management may overcome
obstacles to improving the culture of
nursing homes and resident care.
Project Title: Organization Change to
Improve Nursing Home Environment
Research Area: WC
AHRQ Grant: HS11976
Principal Investigator: Jules Rosen,
M.D.
Reference: Rosen J, Mittal V,
Degenholtz H, Castle N, Mulsant BH,
Hulland S, Nace D, Rubin F. Ability,
incentives, and management feedback:
organizational change to reduce pressure
ulcers in a nursing home. J Am Med
Dir Assoc 2006 May-Jun;7(3):141-6.
Staffing impacts the rate of worker
injuries in long-term care. For nursing
home employees, the workplace is
fraught with hazards and, as institutions
face increasing pressure to perform more
efficiently, the response is often lower
staffing levels, higher patient loads, and
increased chances for worker injuries.
AHRQ researchers examined the impact
of staffing on worker injuries in all
Medicare-approved nursing homes
throughout Maryland, West Virginia,
and Ohio. Total RN, licensed practical
nurse, and nursing aide hours per
resident day across the three states
(ranging from 3.2 to 3.6 hours per
resident day) showed a statistically
significant association with worker
injury rates in these homes. Each
additional hour of nursing care per
resident day was predicted to reduce worker injuries by as much as 2.4
injuries per 100 full-time workers. Past
studies have demonstrated a clear link
between worker injuries and turnover;
thus, researchers point out that it is
imperative to preserve worker well-being
in the face of impending shortages in
long-term care staff.
Project Title: Do Organizational
Factors Influence Both Patient &
Worker Outcomes?
Research Area: WC
AHRQ Grant: HS11990
Principal Investigator: Alison Trinkoff,
M.P.H., Sc.D., Ph.D., F.A.A.N.
Reference: Trinkoff AM, Johantgen M,
Muntaner C, Le R. Staffing and worker
injury in nursing homes. Am J Public
Health 2005 Jul;95(7):1220-5.
Return to Contents
Education and Training
National AHRQ Patient Safety
Network Web site Continues to
Grow. The Web site, AHRQ Patient
Safety Network, or AHRQ PSNet, is a
national "one-stop" portal of resources
for improving patient safety and
preventing medical errors. AHRQ
PSNet is the first comprehensive effort
to help health care providers,
administrators, and consumers learn
about all aspects of patient safety. The
site provides a wide variety of patient
safety resources, information on tools
and conferences, and more. AHRQ
PSNet users can customize the site
around their unique interests and needs
by creating a "My PSNet" page. In
addition, weekly AHRQ PSNet updates
are available to subscribers on patient
safety findings, literature, tools, and
conferences. Additionally, a carefully
annotated collection of seminal patient
safety journal articles resides in a
"Classics" section. Visit the AHRQ
PSNet at http://psnet.ahrq.gov/.
The successful AHRQ WebM&M
continues to attract new users. The
AHRQ WebM&M Web site publishes
illustrative cases of medical errors on the
Internet, accompanied by expert
commentaries, references, and
opportunities to earn continuing
medical education (CME) credits and
continuing educational units (CEUs). It
also includes a section on perspectives
on safety and a "Did You Know?"
section. AHRQ WebM&M is modeled
on hospital morbidity and mortality
conferences; three cases are posted each
month to illustrate diverse patient safety
issues, and case discussions are provided.
The Web site, which had more than
30,000 visitors in its most recent
month, has become a very popular
source for medical error case discussions
and has garnered highly positive
feedback. AHRQ WebM&M represents
one of the most successful on-line
journals involving patient safety and
medical error discussions.
Project Title: Develop, Implement,
Maintain, and Assess a National
Electronic Web-based Morbidity and
Mortality Conference Site
AHRQ Project No: 290-01-0011
Principal Investigator: Robert Wachter,
M.D.
Reference:Wachter RM, Shojania KG,
Minichiello T, Flanders SA, Hartma EE.
AHRQ WebM&M-online medical
error reporting and analysis. In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to Implementation.
Vol. 4, Programs, Tools and Products.
AHRQ Publication No. 05-0021-4.
Rockville, MD: Agency for Healthcare
Research and Quality; Feb 2005. pp.
211-21.
Improving patient safety through
Web-based education. The National
Patient Safety Foundation collaborated
with physicians, nurses, patient
representatives, and educators
throughout the United States to develop
a standard method of patient safety
education. Three interactive educational
modules were developed: one each for
physicians, nurses, and patients. The
physician's module offers a total of six
continuing medical education (CME)
credits, and the nurse's module offers
continuing educational units (CEUs).
The patient's module provides
fundamental information to achieve safe
patient care. The Web sites are:
- Physicians: http://www.npsf.org/html/mcw/physicians.html
- Nurses: http://www.npsf.org/html/mcw/nurses.html
- Patients: http://www.npsf.org/html/patients_Web.html
Project Title: Improved Patient
Safety through Web-Based
Education
Research Area: Dis-ED
AHRQ Grant: HS12043
Principal Investigator:William
Hendee, Ph.D.
Video monitoring of emergency
care improves patient safety. Video
recording is a powerful tool for
documenting clinician performance and
revealing safety and systems issues not
identified by human observation.
AHRQ researchers employed video
recording to document the real
emergency procedures and critical
events in a trauma center and identified
patient safety, clinical, quality assurance,
and ergonomic issues, as well as systems
failures. They suggest that video
recording is a useful feedback and
training tool and provides a reusable
record of events that can be repeatedly
reviewed and used as research data. In
addition to improving patient safety,
participation in video recording was
beneficial to health care providers also,
as they could review the universal
precautions to protect themselves and
develop best practices for emergency
care.
Project Title: Brief Risky High Benefit
Procedures: Best Practice Model
Research Area: SRBP
AHRQ Grant: HS11279
Principal Investigator: Colin
Mackenzie, M.D.
Reference: Mackenzie CF, Xiao Y.
Video techniques and data compared
with observation in emergency trauma
care. Qual Saf Health Care 2003
Dec;12:Suppl 2, ii51-7.
SimCare: An assessment and
teaching tool for diabetes care. A
major factor in the high rates of medical
error in the treatment of patients with
diabetes and other chronic diseases is the
complexity of the tasks that physicians
must complete. AHRQ researchers
developed SimCare, a dynamic and
interactive model that simulates diabetes
management in the office-based practice
setting. SimCare presents a series of
cases based on clinical situations
representing task features that are
thought to be the source of both realistic
care decisions and medical errors.
Physicians select treatment options from
an unguided set of choices similar to
those available in routine office practice.
The cumulative record of the chosen
treatment moves is available for analysis
and comparison with an expert's
sequence of moves for each simulated
patient. SimCare is potentially both an
assessment and a teaching tool that
enables the observation and analysis of
physician decisionmaking in the
simulated practice setting.
Project Title: Physician intervention to
improve diabetes care.
AHRQ Grant: HS10639
Principal Investigator: Patrick J.
O'Connor, M.D., M.P.H.
Reference: Dutta P, Biltz GR, Johnson
PE, Sperl-Hillen JM, Rush WA,
Duncan JE, O'Connor PJ. SimCare: a
model for studying physician
decisionmaking activity. In: Henriksen
K, Battles JB, Marks ES, Lewin DI,
editors. Advances in Patient Safety: From
Research to Implementation. Vol. 4,
Programs, Tools and Products. AHRQ
Publication No. 05-0021-4. Rockville,
MD: Agency for Healthcare Research
and Quality; Feb 2005. pp. 179-92.
Simulator provides a reliable
assessment of technical skills vital
to mastering minimally invasive
endoscopic sinus surgeries. A
simulator training curriculum was
developed with the endoscopic sinus
surgery simulator (ES3) and validated
by 34 medical students and 4
otolaryngology residents. Technical
errors were identified, quantified, used
to train and monitor surgical
performance, and used for outcomes
analysis to improve patient safety.
Examples of current validated metrics
include: time-to-completion, errors,
economy of motion, and psychomotor
tracking. Correlation with psychometric
parameters (perception, psychomotor,
visiospatial, cognitive mapping, etc.) will
be used to identify technical errors and
to validate the simulator and the
curriculum. Scores on the ES3, correlate
highly with scores on previously
validated measures of perceptual,
visiospatial, and psychomotor
performance.
Project Title: Identifying and Reducing
Errors with Surgical Simulation
Research Area: CLIPS
AHRQ Grant: HS11866
Principal Investigator: Marvin Fried,
M.D.
Reference: Arora H, Uribe J, Ralph W,
Zeltsan M, Cuellar H, Gallagher A,
Fried MP. Assessment of construct
validity of the endoscopic sinus surgery
simulator. Arch Otolaryngol Head Neck
Surg 2005 Mar;131(3):217-221.
Discovering the cognitive causes of
errors may help detection and
prevention. AHRQ researchers studied
the electronic recording and
presentation of clinical information
from a cognitive point of view, studying
various levels of clinician expertise. The
group found that structured (rather than
narrative) data resulted in better recall
and better inferences for novice and
intermediate level clinicians. This
suggests a need for structured data entry
or effective natural language processing
to structure the data to help reduce
errors. In addition, various stakeholders
(administrators, engineers, nurses, and
physicians) interpret error causation
differently, and there was a greater
tendency to assign human blame to
errors when errors were presented
retrospectively.
Project Title: Mining Complex Clinical
Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George
Hripcsak, M.D.
Reference: Bakken S, Cimino JJ,
Hripcsak G. Promoting patient safety
and enabling evidence-based practice
through informatics. Med Care 2004
Feb;42(2 Suppl):II49-56.
*National curriculum targets
improvement in the culture of
patient safety by developing
interprofessional leadership and
collaboration. AHRQ researchers
participated in the creation of the
Faculty Leadership in Interprofessional
Education to Promote Patient Safety
(FLIEPPS) curriculum, which consists
of an online five-module handbook on
best practices in patient safety and an
optional for-purchases online patient
safety tutorial. Themes addressed by the
handbook include: patient safety basics,
developing academic leadership,
improving practice safety culture and
the response to error, and applying
principles of teaching and learning to
encourage active participation in the
curriculum.
Project Title: Faculty Leadership in
Interprofessional Education to Promote
Patient Safety (FLIEPPS)—A
Collaborative Agreement with HRSA
Research Area: HRSA
AHRQ Grant: D50 HP 10006
Principal Investigator: Pamela
Mitchell, Ph.D., R.N.
Reference: Mitchell PH, Robins LS,
Schaad D. Creating a curriculum for
training health profession leaders. In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to
Implementation. Vol. 4. Programs,
Tools, and Products. AHRQ Publication
Number 05-0021-4. Rockville, MD:
Agency for Healthcare Research and
Quality, Feb. 2005. pp. 299-312.
Web site:
http://www.interprofessional.washington.edu/ptsafety/resources.asp
Return to Contents
Safety in Intensive Care Units (ICUs)
Complicated, error-prone devices
are commonly used in ICUs. The
volume of patient data, lighting level,
ambient noise, and scheduling all result
in provider and patient stress in ICUs.
These difficult working conditions make
errors more probable and are risk factors
for provider burnout and negative
outcomes for patients. AHRQ
researchers identified auditory alarms on
ICU equipment, ICU syndrome
(delirium), and needlesticks as examples
of such problems. They stress that basic
lessons in ergonomics, human factors,
and human performance fail to apply in
the complex medical environment of
the ICU and there is a lot of room for
improvement—from easy access to the
dialysis machine to adjusting the
manpower schedule.
Project Title: Development Center for
Patient Safety Research
Research Area: DCERPS
AHRQ Grant: HS11562
Principal Investigator: Yan Xiao, M.D.
Reference: Donchin Y, Seagull FJ. The
hostile environment of the intensive care
unit. Curr Opin Crit Care 2002
Aug;8(4):316-20.
Most airway events in ICUs are
preventable. More than half of airway
events such as coughing, spasms of the
larynx, excessive salivation and breath
holding, and other complications
involving endotracheal tubes in ICUs
are preventable, according to AHRQ
researchers. To help limit the impact of
these events, researchers suggest that
prevention efforts focus on critically ill
infants and patients with complex
medical conditions. Also, ICU managers
should ensure appropriate staffing to
limit the impact of airway events when
they occur.
Project Title: Intensive Care Unit
Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS14246
Principal Investigator: Peter Pronovost,
M.D.
Reference: Needham DM, Thompson
DA, Holzmueller CG, Dorman T,
Lubomski LH, Wu AW, Morlock LL,
Pronovost PJ. A system factors analysis
of airway events from the Intensive Care
Unit Safety Reporting System
(ICUSRS). Crit Care Med 2004
Nov;32(11):2227-33.
AHRQ researchers provide a
practical framework for increasing
safety in the ICU. Complex systems
such as ICUs are breeding grounds for
errors and the resulting adverse events
because interdependent components
interact in unexpected ways. Patients are
cared for by many providers with
varying levels of expertise across several
disciplines, and these providers use
highly sensitive and potentially
dangerous technologies and
medications. Such complex systems
require careful planning, excellent
teamwork and communication, and
designed redundancies to recheck for
proper care processes. AHRQ
researchers provide a practical
framework for improving patient safety.
Project Title: Statewide Efforts to
Improve Care in Intensive Care Units
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter Pronovost,
M.D.
Reference: Pronovost PJ, Wu AW,
Sexton JB. Acute decompensation after
removing a central line: practical
approaches to increasing safety in the
intensive care unit. Ann Intern Med 2004 Jun 15;140(12):1025-33.
*Comprehensive unit-based safety
program can improve safety
climate and reduce length of stay
and medication errors in the ICU.
Patient safety initiatives are often limited
by scarce data on the safety climate and
by a failure to document improvements
and motivate work unit staff. The
comprehensive unit-based safety
program (CUSP) is an eight-step
program designed to overcome such
weaknesses by empowering staff,
prioritizing safety concerns, and measuring pre- and post-intervention
levels of safety climate and rate of
adverse events. AHRQ researchers
implemented CUSP in two ICUs of an
academic medical center. At the end of
6 months, staff reporting a positive
safety climate increased from 35 percent
to as much as 68 percent. Length of
stay in each ICU decreased significantly
by a full day, and medication errors in
transfer orders were nearly eliminated.
Project Title: Intensive Care Unit
Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter
Pronovost, M.D., Ph.D.
Reference: Pronovost P, Weast B,
Rosenstein B, Sexton JB, Holzmueller
C, Paine L, Davis R, Rubin HR.
Implementing and validating a
comprehensive unit-based safety
program. Journal of Patient Safety
2005. Mar;1(1):33-40.
Return to Contents
For More Information
For additional information on AHRQ-funded patient safety research and findings, please visit the AHRQ Web site at http://www.ahrq.gov/qual/patientsafetyix.htm or the Patient Safety Network at http://psnet.ahrq.gov or contact:
Jeff Brady
Patient Safety Portfolio Leader
AHRQ Center for Quality Improvement and Patient Safety
540 Gaither Road
Rockville, MD 20850
Telephone: (301) 427-1333
E-mail: Jeff.Brady@ahrq.hhs.gov
* Items marked with an asterisk (*) are new to this revised Program Brief.
Note: The Research Areas are different funding categories:
- R-DEMO: Reporting System Demonstrations.
- DCERPS: Developing Centers of Excellence in Research on Patient Safety.
- HRSA: Health Resources and Services Administration.
- SRBP: Systems-Related Best Practices.
- WC: Effects of Working Conditions on Patient Safety.
- CLIPS: Clinical Informatics and Patient Safety.
- Dis-ED: Patient Safety Research Dissemination and Education.
- COE: Centers of Excellence for Patient Safety Research and Practice.
- TRIP: Translating Research into Practice.
- CERTs: Centers for Education and Research on Therapeutics.
- IDSRN: Integrated Delivery Systems Research Networks.
Return to Contents
AHRQ Publication No. 06-P023
(replaces AHRQ Pub. No. 06-P004)
Current as of June 2009
Internet Citation:
Patient Safety Research Highlights. Program Brief. AHRQ Publication No. 06-P023, May 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/psresearch.htm
540 Gaither Road Rockville, MD 20850 