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Preventing Hospital-Acquired Venous Thromboembolism:
A Guide for Effective Quality Improvement
The Patient Experience & Patient Safety Culture: CAHPS®/SOPS User Group Meeting

Medical Errors & Patient Safety

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The very critical issues of medical errors and patient safety have received a great deal of attention. In November 1999, the Institute of Medicine (IOM) released a report estimating that as many as 98,000 patients die as the result of medical errors in hospitals each year.

A major Federal initiative has been launched to reduce medical errors and improve patient safety in federally funded health care programs, and by example and partnership, in the private sector.

Online Journals

PSNet: AHRQ Patient Safety Network
Web M&M: Morbidity & Mortality Rounds Online

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Tools & Resources

Tips for Consumers & Patients

Five Steps to Safer Health Care
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet
20 Tips to Help Prevent Medical Errors in Children
Be Prepared for Medical Appointments
It's Your Health: Use Your Medications Safely
Ways You Can Help Your Family Prevent Medical Errors!


AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk: Interim Report to the Senate
To Err is Human: Building a Safer Health System: Institute of Medicine report
Health Care-Associated InfectionsNew
Improving Patient Safety Through Simulation Research
Medical Errors: The Scope of the Problem
Methodological Shortcomings and Estimates of Adverse Events: Technical Review
National Survey on Consumer Experiences With Patient Safety and Quality
Patient Safety: Achieving a New Standard for Care: Institute of Medicine report on health care data standards
Patient Safety E-newsletter Archives
Patient Safety Research Highlights: Program Brief
Reducing Medical Errors in Health Care: Fact Sheet
Safe Practices for Better Healthcare: Summary: National Quality Forum Consensus Report
Web Chat Transcript: Patient Safety Research
Web M&M: Fact Sheet

Communication & Teamwork

Hospital Survey on Patient Safety Culture
   2008 Comparative Database Submission Information
   2008 Comparative Database Report
   2007 Comparative Database Report
   Nursing Home Survey on Patient Safety: User's GuideNew!
   Nursing Home Survey on Patient Safety Culture: Survey FormsNew!
   (PDF File, 75 KB; PDF Help; Word® File, 170 KB)
   Nursing Home Survey on Patient Safety Culture: Items and DimensionsNew!
Is Our Pharmacy Meeting Patients' Needs?
Medical Teamwork and Patient Safety: The Evidence-based Relation
Strategies to Improve Communication Between Pharmacy Staff and Patients
TeamSTEPPS™: National Implementation (Web Site)

Design & Working Conditions

The Effect of Health Care Working Conditions on Patient Safety: Evidence Report
The Hospital Built Environment: What Role Might Funders of Health Services Research Play?
Transforming Hospitals: Designing for Safety and Quality
   DVD Available

Implementation & Transformation

10 Patient Safety Tips for Hospitals
30 Safe Practices for Better Health Care
Advances in Patient Safety: New Directions and Alternative ApproachesNew!
Advances in Patient Safety: From Research to Implementation
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders
Closing the Quality Gap: Quality Improvement Strategies
Closing the Quality Gap: Diabetes Care Strategies
Closing the Quality Gap: Hypertension Care Strategies
Consumer Financial Incentives: A Decision Guide for Purchasers
Developing a Community-Based Patient Safety Advisory Council
Mistake-Proofing the Design of Health Care Processes
Partnerships in Implementing Patient Safety (PIPS)
   Patient Safety Tools: Improving Safety at the Point of Care
   Patient Safety Tools: Program Brief
Patient Safety Improvement Corps: 2007-08 State Organizations
   DVD for Institutional Training
Patient Safety Challenge Grants: Translating Research Into Practice
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Priority Areas for National Action: Transforming Health Care Quality
Purchaser-Provider Synergies
Reducing Errors in Health Care
Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs
Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory CareNew!
Toolkit for Redesign in Health Care

Patient Safety Organizations (PSOs)

Patient Safety Organizations: Web SiteNew!
Patient Safety and Quality Improvement Act of 2005

Patient Safety Research & Funding Opportunities

Advances in Patient Safety: From Research to Implementation
Ambulatory Safety and Quality Program: Health IT Portfolio
Funding Opportunities
   Active: Requests for Applications, Program Announcements, Contracts
   Archived: Grants and Contracts

Tools & Techniques

AHRQ Patient Safety Tools and ResourcesUpdated
Automated Telephone Reminders
How to Create a Pill Card
Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality ImprovementNew!
Problems and Prevention: Chest Tube Insertion
Tools, Methods, and Techniques for Improving Patient Safety

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Conferences & Workshops

AHRQ's Quality Challenge Summit (Video)
Agenda for Research in Ambulatory Patient Safety: Conference Synthesis
Can You Minimize Health Care Costs by Improving Patient Safety? (Web Conference)
Improved Patient Safety: Sharing Issues, Successes, and Challenges Across States: Workshop Brief
Improving Patient Safety In Rural Hospitals: A Workshop With Wisconsin Health Care Leaders
Making the Health Care System Safer: Second Annual Patient Safety Research Conference
Making the Health Care System Safer: Third Annual Patient Safety Research Conference
Partnerships in Implementing Patient Safety (Technical Assistance)

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Speeches & Statements

Date   Title
9/27/06 Remaking American Medicine: Carolyn Clancy, M.D
9/25/06 The Culture of Safety: Carolyn Clancy, M.D
10/25/05 Health Information Technology, Quality of Care, and Evidence-based Medicine: An Interlinked Triad: Carolyn Clancy, M.D
9/9/05 Health Information Technology and the "Quality Movement": Carolyn Clancy, M.D
6/8/05 Quality Is the Goal for Patient Safety and Health IT: Carolyn Clancy, M.D.

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Congressional Hearings

Date   Title
6/9/05 Testimony on Patient Safety Activities at HHS: Carolyn Clancy, M.D.
3/19/04 Testimony on Health Care Quality Initiatives: Carolyn Clancy, M.D.
6/11/03 Testimony on Patient Safety: Carolyn Clancy, M.D.

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AHRQ Advancing Excellence in Health Care