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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - about the safety event(s) and the circumstances surrounding it, using them to systematically detect and measure … being used at the private-sector, state, and federal levels as part of internal safety improvement programs … events across large populations of patients over time.( 15 ) One example of an administrative data–based measure … Given the increased use of quality and safety measures for hospital-level public reporting and pay-for-performance … April 10, 2024
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators
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psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
February 07, 2024 - This scoping review explored the use of measures to capture pediatric medication errors in ambulatory … The authors identified 142 studies evaluating 21 measures of medication errors, including measures of … Only 31 studies assessed measure reliability. … February 15, 2023
Implementation of the I-PASS handoff program in diverse clinical environments … Resources
Annual Perspective
Improving Diagnostic Safety and Quality
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psnet.ahrq.gov/issue/medication-safety-certificate-program
September 30, 2020 - April 1, 2015
Move toward full use of metric dosing: eliminate dosage cups that measure … Use cups that measure mL. … February 26, 2014
2005 Quest for Quality Prize. … February 1, 2022
- March 8, 2022
Master of Healthcare Quality and Safety. … October 15, 2018
Safety Quality and Informatics Leadership Program.
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psnet.ahrq.gov/Information/Editor
measures, using outcomes data to improve the quality and effectiveness of health care, and studying … and outcomes of health care, refining, validating, and adapting measures that can be used to provide … Payment Program. … She has extensive experience managing research projects of varying scales and complexities, particularly … for Medicare and Medicaid (CMS) and their respective quality indicator and patient safety programs.
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psnet.ahrq.gov/issue/comprehensive-obstetric-patient-safety-program-reduces-liability-claims-and-payments
June 22, 2017 - , standardizing care protocols, and establishing a robust quality assurance mechanism (including a dedicated … December 4, 2016
Sustaining reliability on accountability measures at the Johns Hopkins … January 30, 2013
A resident-led institutional patient safety and quality improvement … March 21, 2012
The power of collaboration with patient safety programs: building safe … January 10, 2011
Improving America's Hospitals: The Joint Commission's Report on Quality
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psnet.ahrq.gov/issue/comparison-health-care-worker-satisfaction-vs-after-implementation-communication-and-optimal
December 09, 2020 - health care worker satisfaction before vs after implementation of a communication and optimal resolution program … AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure … Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in … May 13, 2020
The effect of a Lean quality improvement implementation program on surgical … November 17, 2017
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Hospitals
Quality
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psnet.ahrq.gov/issue/customized-triggers-program-childrens-hospitals-experience-improving-trigger-usability
September 01, 2021 - Study
A customized triggers program: a children's hospital's experience in improving … A customized triggers program: a children's hospital's experience in improving trigger usability. … events in near real-time to facilitate appropriate preventative measures. … February 16, 2022
Making the business case for quality and safety. … 12, 2008
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Children's Hospitals
Quality
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psnet.ahrq.gov/issue/new-cms-hospital-quality-star-ratings-stars-are-not-aligned
May 26, 2021 - The authors offer recommendations to CMS to improve their comparison program, including reducing the … number of measures tracked, investing more in quality measurement at a national level, and developing … March 27, 2017
Associations between hospital characteristics, measure reporting, and … with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program … Related Resources
Unintended harm associated with the Hospital Readmissions Reduction Program
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psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
October 30, 2024 - Program) that reduces reimbursement to hospitals with elevated rates of a range of HACs. … The program measures HAC rates by a composite Patient Safety Indicator (PSI90), which includes 10 specific … , 2024
Defects in value associated with hospital-acquired conditions: how improving quality … November 29, 2017
Effect of a hospital-wide measure on the readmissions reduction program … 2017
From board to bedside: how the application of financial structures to safety and quality
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psnet.ahrq.gov/issue/partnering-va-stakeholders-develop-comprehensive-patient-safety-data-display-lessons-learned
September 25, 2019 - measures related to safety in a single location in order to facilitate collaboration at local sites. … Improvement Program and the Patient Safety Indicators. … May 19, 2014
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … 2011
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs
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psnet.ahrq.gov/issue/engagement-leadership-quality-improvement-initiatives-executive-quality-improvement-survey
October 04, 2006 - Study
Engagement of leadership in quality improvement initiatives: executive quality … Citation Text:
Engagement of leadership in quality improvement initiatives: executive quality improvement … July 14, 2010
A simulation systems testing program using HFMEA methodology can effectively … November 18, 2016
A program to prevent catheter-associated urinary tract infection in … March 2, 2016
Sustaining reliability on accountability measures at the Johns Hopkins
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psnet.ahrq.gov/issue/sepsis-quality-safety-net-hospitals-analysis-medicares-sep-1-performance-measure
May 05, 2021 - measure. … Sepsis quality in safety-net hospitals: An analysis of Medicare's SEP-1 performance measure. … The 703 safety-net hospitals performed worse on the CMS SEP-1 quality measure and this association was … Sepsis quality in safety-net hospitals: An analysis of Medicare's SEP-1 performance measure. … June 21, 2017
Combined impact of Medicare's hospital pay for performance programs on
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psnet.ahrq.gov/issue/effects-brief-team-training-program-surgical-teams-nontechnical-skills-interrupted-time
December 08, 2021 - Study
Effects of a brief team training program on surgical teams' nontechnical skills … Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series … This Australian hospital implemented a team training program for surgical teams focused on improving … December 8, 2021
Strength of safety measures introduced by medical practices to prevent … January 9, 2008
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Operating Room
Quality
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. … These indicators could be outcome measures such as risk adjusted mortality, adverse events (measured … to see if actual harm occurred [ 5 , 6 ]), incident reports, nosocomial infection rates, and process measures … In large organizations, the quality people are managing performance on scorecards, on CMS measures, on … Every one of those steps is done in some measure by a human being, which means that it has an intrinsic
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psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-review
October 12, 2022 - This scoping review includes 63 studies that collectively reported on 47 instruments or scales used to … March 9, 2022
Moving towards a core measures set for patient safety in perioperative … September 23, 2020
Effect of a quality improvement intervention with daily round checklists … October 18, 2023
Relationship of the nursing practice environment with the quality of … November 29, 2023
Implementation of the I-PASS handoff program in diverse clinical environments
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - Building on a model of structure, process, and outcome measures used to evaluate health care quality, … the authors present a detailed discussion of attributes necessary for safety-specific measures. … February 13, 2018
A comprehensive perinatal patient safety program to reduce preventable … December 23, 2016
Adherence to simple and effective measures reduces the incidence of … study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - financial resource strain, and transportation.3 The goal of
this innovation was to improve healthcare quality … , both in quality scores and measures.3 The program was
implemented across UNC Health’s 92 primary care … to community resources and supports, such as housing
support, food banks, and financial assistance programs … Standardized measures should be designed to collect simple screening information. … Teamwork in healthcare: key discoveries enabling
safer, high-quality care.
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care. … From the Same Author(s)
Comparing catheter-associated urinary tract infection prevention programs … Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures … October 17, 2017
A program to prevent catheter-associated urinary tract infection in … Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures
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psnet.ahrq.gov/issue/when-agency-fails-analysis-association-between-hospital-agency-staffing-and-quality-outcomes
September 11, 2024 - When agency fails: an analysis of the association between hospital agency staffing and quality … measures. … measures, including Hospital Compare star rating and Hospital Value-Based Purchasing (VBP) Total Performance … measures and financial performance. … trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program
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psnet.ahrq.gov/issue/publicly-available-hospital-comparison-web-sites-determination-useful-valid-and-appropriate
December 21, 2014 - measures. … July 6, 2022
Repurposing clinical decision support system data to measure dosing errors … November 14, 2011
Adherence to Surgical Care Improvement Project measures and the association … Improvement program data. … Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure