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Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs) including never events and health care associated infections for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings. -
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innov
This proposed rule suggests updates to the government requirements hospitals must comply with to participate in Medicare and Medicaid. Changes include emphasis on the role of leadership engagement and safety culture as ways to generate improvements in areas such as reducing hospital-acquired infections and readmissions. Comments on the proposed rule are due August 15, 2016. -
State and Regional Demonstration in Health Information Technology: Indiana (Indiana) | AHRQ National
You are here Home Funded Projects State and Regional Demonstration in Health Information Technology: Indiana (Indiana) | More Search AHRQ-Funded Proje ... -
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. | AHRQ Patient Sa
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation and highlights the role of mobile technologies and electronic health records in continuously improving health care. -
The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a yea
This commentary reveals how one large health care system successfully reduced preventable deaths and suggests that adopting principles from high reliability organizations can improve safety. -
Patient safety in palliative care: a mixed-methods study of reports to a national database of seriou
The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care. -
Improving health care quality and patient safety through peer-to-peer assessment: demonstration proj
Patient safety approaches often draw from high reliability industries outside of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear power industry. Two academic medical centers assessed each other's patient safety performance. Each center examined its peer's prevention of central line associated bloodstream infections (CLABSI), hand hygiene compliance, and overall safety culture as an organization. Peer-to-peer assessments were conducted via site visits, which involved interviews and direct observation. They resulted in rapid practice changes such as dissemination of unit-specific CLABSI rates and central line procedure audits. The process was widely accepted by leaders and frontline staff at both sites. The authors contend that peer-to-peer assessment is feasible and has potential to improve patient safety. -
Improving communication with primary care physicians at the time of hospital discharge. | AHRQ Patie
Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement. -
A Crisis in Health Care: A Call to Action on Physician Burnout. | AHRQ Patient Safety Network
Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers. -
Improving clinical handover between intensive care unit and general ward professionals at intensive
This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness. -
State-mandated hospital infection reporting is not associated with decreased pediatric health care a
Some states require public reporting of rates of central line associated bloodstream infections (CLABSI). Investigators did not find differences in CLABSI rates between states with and without public reporting, suggesting that current transparency efforts are not sufficient to improve this safety target. -
The Wise App Trial for Improving Health Outcomes in PLWH (New York) | AHRQ National Resource Center;
You are here Home Funded Projects The Wise App Trial for Improving Health Outcomes in PLWH (New York) | More Search AHRQ-Funded Projects AHRQ-Funded P ... -
AHRQ Announces Interest in Health Services Research to Address the Opioids Crisis. | AHRQ Patient Sa
This announcement highlights Agency for Healthcare Research and Quality funding opportunities for health services research to assess local, state, and system-level policy to address the opioid crisis, evaluate interventions to minimize opioid misuse, and understand the rapid increase in opioid-related hospitalizations. -
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Reporting on the current state of the drug shortage problem and its causes, this publication examines FDA efforts to proactively identify potential shortages and recommends enhanced policies and procedures for data management to augment this work. -
Using Report Cards to Measure Racial and Ethnic Health Disparities: State Experience
Using Report Cards to Measure Racial and Ethnic Health Disparities: State Experience September 26, 2011 Prepared by Carrie Hanlon, MA Introduction Sta ...https://hcup-us.ahrq.gov/reports/race/ReportcardsIB.jsp - 20k - 2019-04-01 -
From a blame culture to a just culture in health care. | AHRQ Patient Safety Network
This article argues that a deep understanding of an organization's blunt end capacity toward blame is needed in order to enable a shift to a just culture. -
Improving Data & Enhancing Access (IDEA-NW) Project
Improving Data & Enhancing Access (IDEA-NW) Project A presentation that describes the results of a record linkage project between NTR and various publ ...https://hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or28.jsp - 7k - 2019-04-01 -
We need to talk: primary care provider communication at discharge in the era of a shared electronic
Primary care physicians at an academic medical center continued to speak up about concerns regarding the quality of communication they received from inpatient teams even after implementation of a shared electronic medical record. They also expressed a desire for increased direct communication at discharge for complex patients and patients with detailed follow-up needs. -
State and Regional Demonstrations in Health Information Technology | AHRQ National Resource Center;
You are here Home State and Regional Demonstrations in Health Information Technology | More State and Regional Demonstrations in Health Information Te ... -
Clinical and financial effects of smart pump electronic medical record interoperability at a hospita
Smart pumps offer both benefits and drawbacks that can affect medication safety. This case study describes the implementation of a smart pump electronic medical record interoperability program at a single hospital. The authors report a positive impact on both revenue and patient safety.