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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/e1_combo_monitorprogress.pdf
June 02, 2025 - monitor after implementation will include rates for the AHRQ Inpatient Quality
Indicators (IQIs), Patient … If these
sources do not provide the needed data, you can use chart abstractions, surveys, new
administrative … To produce accurate reports for measures
that are calculated as rates (e.g., percentage of patients … with postsurgical infections), it is
important to have complete counts for the relevant patient populations … (e.g., all patients
who had surgery during a time period).
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psnet.ahrq.gov/issue/shortage-perioperative-drugs-implications-anesthesia-practice-and-patient-safety
April 11, 2018 - Shortage of perioperative drugs: implications for anesthesia practice and patient safety. … association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey … February 3, 2011
Recommendations for the safety of hospitalised patients in the context … June 19, 2024
Factors determining safety culture in hospitals: a scoping review. … September 24, 2016
Practice advisory on anesthetic care for magnetic resonance imaging
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psnet.ahrq.gov/issue/medication-errors-and-response-bias-tip-iceberg
February 07, 2024 - A very low response rate to a physician survey on medication errors could be attributed to lack of training … October 1, 2008
Utility of clinical examination in the diagnosis of emergency department patients … Safety
March 27, 2024
What has been the impact of Covid-19 on safety culture … patient safety concepts in undergraduate medical students. … of incident reports for patient safety.
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psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis
May 11, 2022 - April 22, 2020
Patient Safety: A Health Affairs Briefing. … June 19, 2019
Health IT Patient Safety Supplemental Items for Hospitals. … September 29, 2017
The impact of drug shortages on children with cancer—the example of … September 7, 2016
Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety … Culture.
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psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-obtaining-himss-stage-7
July 17, 2019 - Electronic health records (EHRs) have been widely adopted as a strategy to improve patient safety. … March 22, 2023
Hospital Survey on Patient Safety Culture: 2011 User Comparative Database … 27, 2024
Investigating the impact of cognitive bias in nursing documentation on … based on feedback from former psychiatric patients. … April 8, 2020
Special Issue on Medication Safety.
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
October 01, 2014 - Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn from Mistakes and Improve Safety … Culture
Chris Goeschel, ScD MPA MPS RN FAAN
Director, Strategic Development and Research Initiatives … An intervention to learn from mistakes and improve safety culture. … Ensuring all patients receive the best practices. … Safety survey to identify at-risk departments.
Mandatory science of safety training.
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psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
June 08, 2022 - ' perceptions of patient safety culture: a cross-national cross-sectional study. … on healthcare quality? … A survey study. … Monitoring preventable adverse events and near misses: number and type identified differ depending on … January 11, 2023
Suicide and suicide attempts on hospital grounds and clinic areas.
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psnet.ahrq.gov/issue/patient-safety-near-misses-still-missing-opportunities-learn
July 10, 2024 - the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients … performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey … View More
Related Resources
Effect of interventions to improve safety … culture on healthcare workers in hospital settings: a systematic review of the international literature … February 1, 2023
The effect of a system-level tiered huddle system on reporting patient
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psnet.ahrq.gov/issue/perchance-think
December 08, 2016 - February 28, 2024
National survey of patient safety experiences in hospital medicine … September 25, 2024
Drug-drug interactions and actual harm to hospitalized patients: a … April 10, 2024
The benefits and opportunities: engaging patients in identifying and reporting … patient safety incidents. … April 10, 2019
WebM&M Cases
What Happened on Telemetry
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psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international-survey
September 07, 2022 - Characteristics of critical incident reporting systems in primary care: an international survey … Characteristics of critical incident reporting systems in primary care: an international survey. … ); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central … March 23, 2022
Impact of the COVID-19 pandemic on the experiences of hospitalized patients … July 27, 2022
Impact of providing patients access to electronic health records on quality
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psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning-practices-and-medication
August 30, 2017 - and risk factors in patients visiting a post-COVID-19 outpatient clinic. … and nature of harm to patients in hospital. … March 29, 2012
Measurement for improvement: a survey of current practice in Australian … November 9, 2011
Nurses' perception of error reporting and patient safety culture in … January 7, 2011
Professional commitment, patient safety, and patient-perceived care quality
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psnet.ahrq.gov/issue/complicated-medical-missteps-are-not-inevitable
August 30, 2023 - argues for system approaches to address normalized complacency regarding complications focused on … March 25, 2020
Combined impact of Medicare's hospital pay for performance programs on … August 10, 2022
Influence of organizational climate and clinician morale on seclusion … January 28, 2015
Survey of the national drug shortage effect on anesthesia and patient … safety: a patient perspective.
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psnet.ahrq.gov/issue/counterheroism-common-knowledge-and-ergonomics-concepts-aviation-could-improve-patient-safety
November 03, 2015 - Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient … Related Resources From the Same Author(s)
Effect of a postdischarge virtual ward on … readmission or death for high-risk patients: a randomized clinical trial. … September 21, 2011
The business case for patient safety. … 2009
Self-reported adverse events in health care that cause harm: a population-based survey
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psnet.ahrq.gov/issue/incidence-adverse-events-among-home-care-patients
December 04, 2015 - The incidence of adverse events among home care patients. … May 5, 2021
What has been the impact of Covid-19 on safety culture? … June 28, 2017
Assessing adverse events among home care clients in three Canadian provinces … December 29, 2014
Identification of serious and reportable events in home care: a Delphi survey … December 13, 2013
Assessing adverse events among home care clients in three Canadian
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psnet.ahrq.gov/issue/improving-patient-safety-hospitals-contributions-high-reliability-theory-and-normal-accident
October 13, 2010 - Commentary
Improving patient safety in hospitals: contributions of high-reliability … Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on … September 24, 2017
Effect of day of the week on short- and long-term mortality after … June 8, 2011
Development of a high-value care culture survey: a modified Delphi process … May 4, 2014
Oversight Hearing on Recent Patient Safety Issues.
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psnet.ahrq.gov/issue/lack-awareness-community-acquired-adverse-drug-reactions-upon-hospital-admission-dimensions
October 16, 2013 - October 19, 2022
Patient and visitor aggression in healthcare: a survey exploring organisational … safety culture and team efficacy. … June 22, 2010
Using the Global Trigger Tool in surgical and neurosurgical patients: a … September 7, 2022
EAU policy on live surgery events. … 2008
Concealed renal insufficiency and adverse drug reactions in elderly hospitalized patients
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psnet.ahrq.gov/node/37054/psn-pdf
September 30, 2011 - Impact of the nurse shortage on hospital patient care:
comparative perspectives. … Impact of the nurse shortage on hospital patient care: comparative
perspectives. … demonstrated a link between lower nurse staffing, increased mortality rates, and
worsened performance on … CEOs) and chief nursing officers (CNOs) regarding their perception of the
impact of nursing shortages on … While all respondents agreed that the
current nursing shortage is serious, physicians and CEOs generally
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
August 01, 2023 - Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. … A qualitative study of expert and team cognition on complex patients in the pediatric intensive care … Patient Safety Culture, Health Information Technology Implementation, and Medical Office Problems That … Resilient health care: turning patient safety on its head. Int J Qual Health Care . … Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient
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psnet.ahrq.gov/issue/multiple-patient-safety-events-within-single-hospitalization-national-profile-us-hospitals
November 13, 2009 - July 10, 2017
Adverse-event-reporting practices by US hospitals: results of a national survey … September 12, 2012
A review of patient safety measures based on routinely collected hospital … April 18, 2012
Effect of illness severity and comorbidity on patient safety and adverse … March 3, 2011
Exploring relationships between hospital patient safety culture and adverse … September 2, 2009
Impact of date stamping on patient safety measurement in patients undergoing
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - sessions
hours
Recommendations
Integration
Recommend work-
system factors for
improvement based on … . huddles, closed-loop communication,
periodic planning, and updates)
1g Learns together, focuses on … behaviors averaged slightly above 2, with an overall average of 2.1 (range 1.9-2.2)
40
TENTS vs Patient … them from happening again. 84 +14
In this unit, we are informed about changes that are
made based on … At the unit level: Identify positive and negative aspects of culture
of patient safety and relate them