Patient Safety Case Studies by Year Impact Case Studies and Knowledge Transfer Case StudiesThis portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury associated with delivery of health care. Important goals include: providing information on the scope and impact of medical errors, identifying the root causes of threats to patient safety, and examining effective ways to make system-level changes to help prevent errors. Disseminating and translating research findings and methods to reduce errors are also important. Additionally, the portfolio aims to develop an environment or culture within health care settings that encourages health professionals to share and report information about medical errors and ways to prevent them. 2013Hospitals in Colombia Use AHRQ's Hospital Survey on Patient Safety CultureNational Network of Libraries of Medicine, South Central Region Incorporates AHRQ Resources in Training Librarians2012Alliant/GMCF Uses AHRQ Patient Safety Surveys and TeamSTEPPS® in Nursing Homes and HospitalsPrimary Health Care Centers Use AHRQ Materials to Help Patients Use Blood Thinners SafelyGeorgia QIO Uses AHRQ DVD and Brochure to Educate Medicare Patients About Safe Use of Blood ThinnersMontgomery Memorial Hospital Uses TeamSTEPPS® to Improve Emergency CareVCU Health Systems Clinic Uses AHRQ DVD and Brochures to Educate Patients About Safe Use of Blood ThinnersTemple University Hospital Uses AHRQ Materials to Educate Patients About Safe Use of Blood ThinnersMassachusetts Hospital Improves Medication Reconciliation With AHRQ ToolkitGeorgia Hospitals Improve Medication Reconciliation ProcessTwo Indiana Facilities Revise Their Medication Reconciliation Process as a Result of Participating in an AHRQ ProjectMaryland Hospitals Revise Medication Reconciliation Process as a Result of Participating in an AHRQ ProjectMissouri Hospitals Improve Medication Reconciliation ProcessMichigan Providers Improve Medication Reconciliation ProcessNebraska Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)New Mexico Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)New York Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)Woodhull Medical and Mental Health Center Implements Triage System to Improve CareHebrew Rehabilitation Center Incorporates AHRQ's Project RED Into Demonstration ProjectCleveland Clinic Health System Facility Implements AHRQ's Emergency Severity IndexUniversity of Kentucky HealthCare Improves Emergency Care Using Door-to-Doc ToolkitCapital Health Influenced by AHRQ's Project RED in Creating Tool for PatientsSouth Dakota State University Integrates TeamSTEPPS® Into College of Nursing CurriculumTel Aviv Sourasky Medical Center Uses AHRQ's Comprehensive Unit-Based Safety ProgramNewman Memorial Hospital Implements AHRQ's Patient Safety Culture SurveyMain Line Health System Uses Patient Safety Culture Survey in Suburban Philadelphia Facilities2011IFMCFletcher Allen Health CareOSF Medical GroupPreventing Hospital-Acquired Venous Thromboembolism (VTE)—IdahoPreventing Hospital-Acquired Venous Thromboembolism (VTE)—IndianaPreventing Hospital-Acquired Venous Thromboembolism (VTE)—KentuckyPreventing Hospital-Acquired Venous Thromboembolism (VTE)—New YorkPreventing Hospital-Acquired Venous Thromboembolism (VTE)—North CarolinaPreventing Hospital-Acquired Venous Thromboembolism (VTE)—South CarolinaPreventing Hospital-Acquired Venous Thromboembolism (VTE)—WashingtonMedication Reconciliation—IndianaMedication Reconciliation—KentuckyMedication Reconciliation—Missouri, Part 1Medication Reconciliation—Missouri, Part 2Medication Reconciliation—NebraskaMedication Reconciliation—New Jersey, Part 1Medication Reconciliation—New Jersey, Part 2Medication Reconciliation—New Jersey, Part 3Medication Reconciliation—New YorkMedication Reconciliation—Texas2010Bon Secours St. Mary's HospitalAssociation of periOperative Registered NursesFairview Southdale HospitalCarilion Roanoke Memorial HospitalNorth Dakota Critical Access and Network HospitalsClarinda Regional Health CenterIllinois HospitalsIowa HospitalsNew York HospitalsSociety of Hospital MedicineInstitute for Healthcare ImprovementJennie Edmundson HospitalNebraska Critical Access Hospitals2009National Network of Libraries of MedicineGeorgia Hospital AssociationThe New York City Health and Hospitals CorporationWest Virginia University HospitalsNorthwest MedStarMercy Hospital and Unity Hospital; Allina Hospitals and ClinicsMarshfield Clinic, Family Health Center of Marshfield, Inc.2008American Society of Health-System PharmacistsPremier Inc.SSM Health CareEvanston Northwestern HealthcarePark Nicollet Health ServicesOchsner Health Systems2007AetnaDepartment of DefenseCampbell University School of PharmacyBanner Good Samaritan Medical Center2006Cincinnati Children's Hospital Medical CenterHealthSouthVoice for PatientsHill Country Memorial Hospital; University of Texas Health Center at TylerUniversity of California, Irvine, School of MedicineNorthwestern Memorial HospitalThe State of MinnesotaMultnomah County Health DepartmentHealth Canada2005New Jersey Department of Health and Senior ServicesMaryland Health Care CommissionIndian River Memorial HospitalVeterans Integrated Service Network, Upstate New YorkConnecticut Hospital AssociationLos Angeles County Department of Health ServicesNew York State Department of HealthMethodist Hospital in Southern CaliforniaSummaCare, Inc.Creighton UniversityMemorial Hospital of Union CountySaint Vincent Health CenterThe Leapfrog Group2004Henry Ford Health System Current as of April 2013 Internet Citation: Patient Safety Case Studies by Year: Impact Case Studies and Knowledge Transfer Case Studies. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/case-studies/patient-safety/index.html
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