Patient safety projects funded by the Agency for Healthcare Research and Quality (AHRQ) range from system-wide event reporting methods to specific measures to minimize medical errors. The information here summarizes AHRQ patient safety tools and resources designed for health systems, providers, and consumers.
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Research Findings and Summaries
Advances in Patient Safety: From Research to Implementation. This 140-article, 4-volume set describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety from 1999 to 2004. Included are articles with a research and methodological focus, articles that address implementation issues, and tools to improve patient safety. Available at http://www.ahrq.gov/qual/advances/ or as AHRQ Pub. No. 05-0021-CD.
Advances in Patient Safety: New Directions and Alternative Approaches. This 4-volume set of 115 articles describes new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools to prevent harming patients. It complements AHRQ's Advances in Patient Safety: From Research to Implementation and represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and other important topics. Available at http://www.ahrq.gov/qual/advances2/ or as AHRQ Pub. No. 08-0034 (print copy) or 08-0034-CD (CD-ROM).
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. In this 3-volume handbook, nurses will find peer-reviewed discussions and reviews of a wide range of issues and literature regarding patient safety and quality health care. Each of the 51 chapters and 3 leadership vignettes presents an examination of the state of the science behind quality and safety concepts and challenges the reader to use evidence to change practices and engage in developing the evidence base to address critical knowledge gaps. Available at http://www.ahrq.gov/qual/nurseshdbk/ or as AHRQ Pub. No. 08-0043 (print copy) or 08-0043-CD (CDROM).
Patient Safety Research Highlights. This program brief describes the more than 100 AHRQ-supported studies in patient safety that have produced new findings, tools, and products that the health care system, health care providers, and researchers can use to improve patient safety. Available at http://www.ahrq.gov/qual/psresearch.htm or as AHRQ Pub. No. 06-P023.
Tools for Health Care Providers and Policymakers
AHRQ Web M&M (Morbidity and Mortality Rounds on the Web). This free, peer-reviewed online journal and forum on patient safety and health care quality features expert analysis of medical errors that readers report anonymously, interactive learning modules on patient safety ("Spotlight Cases""), perspectives on safety, and forums for online discussion. Continuing medical education and continuing education unit credits are available. Available at http://www.WebMM.ahrq.gov
Developing a Community-Based Patient Safety Advisory Council. This guide provides approaches for developing a community-based advisory council of patients, consumers, practitioners, and professionals from health care and community organizations to drive change for patient safety through education, collaboration, and consumer engagement. Available at http://www.ahrq.gov/qual/advisorycouncil/ or as AHRQ Pub. No. 08-0048.
Hospital Survey on Patient Safety Culture. Examining patient safety culture from a hospital staff perspective, this survey allows hospitals to assess their safety culture and to track changes in their patient safety culture over time. Available at http://www.ahrq.gov/qual/hospculture/ or as AHRQ Pub. No. 08-0048.
Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. This report gives benchmark data collected voluntarily from nearly 400 U.S. hospitals. Survey results from these hospitals are averaged over the entire sample by topical composite or individual survey item. Two appendixes report the average responses, which are broken down by hospital characteristics or respondent characteristics. Available at http://www.ahrq.gov/qual/hospsurveydb/ or as AHRQ Pub. No. 07-0025.
Medical Office Survey on Patient Safety. Pilot tested in 97 outpatient medical offices, this survey measures issues relevant to patient safety in the ambulatory outpatient medical office setting. It lets providers and staff assess their safety culture, identify areas where improvement is needed, track changes in patient safety, and evaluate the effect of interventions. Researchers can also use the survey to assess patient safety culture improvement initiatives. Available as AHRQ Pub. No. 08-0059 in late 2008.
Mistake-Proofing the Design of Health Care Processes. This guide, illustrated with numerous examples, explains how to apply the industrial engineering concept of mistake-proofing to processes in hospitals, clinics, and physicians' offices. Available at http://www.ahrq.gov/qual/mistakeproof/ or as AHRQ Pub. No. 07-0020 (print copy) or 07-0020-CD (CD-ROM).
Nursing Home Survey on Resident Safety. Pilot tested in 40 nursing homes, this survey uses provider and staff perspectives to assess their nursing home's safety culture, identify areas where improvement is needed, track changes in resident safety, and evaluate the impact of interventions. Researchers can also use the survey to assess safety culture improvement initiatives in nursing homes. Available at http://www.ahrq.gov/qual/nhsurvey08/nhguide.htm or as AHRQ Pub. No. 08-0060.
Patient Safety Organizations. Patient Safety Organizations (PSOs) are designed to improve the quality and safety of U.S. health care by encouraging clinicians and health care organizations to report and share—voluntarily—data on patient safety events without fear of legal discovery.
Organizations eligible to become PSOs include public or private entities; profit or not-for-profit entities; provider entities, such as hospital chains; and other entities that establish special components to serve as PSOs. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data that enable the identification and reduction of the risks and hazards associated with patient care. Available at http://www.pso.ahrq.gov.
Preventing Hospital-Acquired Venous Thromboembolism:A Guide for Effective Quality Improvement. Based on quality improvement initiatives undertaken at the University of California, San Diego
Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients: hospital-acquired venous thromboembolism. Available at http://www.ahrq.gov/qual/vtguide/ or as AHRQ Pub. No. 08-0075.
Transforming Hospitals: Designing for Safety and Quality. By presenting the experiences of three model hospitals that incorporated evidence-based design elements into their construction and renovation projects, this DVD shows hospital staffs how evidence-based design can improve the quality and safety of hospital services. This DVD is an especially useful tool for hospitals that are planning major capital construction projects or minor renovations. Available as AHRQ Pub. No. 07-0076-DVD.
Tools to Share Information
AHRQ PSNet. This national Web-based resource features the latest news and essential resources on patient safety. Items in the AHRQ PSNet collection support a multidisciplinary, systems approach to minimizing errors in health care and come from a range of disciplines and sources, including clinical medicine, health care administration, engineering, general sciences, psychology, equipment and facility design, policy, law, and the media. Its Patient Safety Primers guide users through key concepts in
patient safety with each primer providing background and context and highlighting relevant content from AHRQ PSNet and AHRQ WebM&M. Available at http://psnet.ahrq.gov/about.aspx and http://psnet.ahrq.gov/primerHome.aspx.
Patient Safety and Health Information Technology E-Newsletter. AHRQ's monthly E-newsletter provides timely patient safety and health information technology (IT) news and information. It features concise descriptions of recent findings from AHRQ-supported research and information about new initiatives, upcoming meetings, and other patient safety and health IT activities. A free subscription requires only a computer and an E-mail address. Available by going to http://www.ahrq.gov, selecting "E-mail Updates," and providing the requested information. On the "Quick Subscribe" page, select "Patient Safety and Health Information Technology E-Newsletter."
Training Tools
Problems and Prevention: Chest Tube Insertion. If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury or infection. This 11-minute DVD uses video excerpts of 50 actual chest tube insertions to illustrate
problems that can occur during the procedure. A summary of the recommendations and ordering information for the DVD are available at http://www.ahrq.gov/qual/chesttubes.htm or as AHRQ Pub. No. 06-0069-DVD.
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™). TeamSTEPPS is a set of tools to help train clinicians in teamwork and communication skills to reduce risks to patient safety. The tools include:
- A leader's guide that provides materials for leader training.
- A learner's guide for participants.
- A pocket-sized guide of important team concepts for participants to use in their everyday work.
- A CD for trainers and leaders that includes reproducible materials for local needs.
- A DVD with nine vignettes that illustrates examples of successful and unsuccessful teamwork.
- A module on Rapid Response Systems, in which hospitals use groups of clinicians to bring critical care expertise to patients requiring immediate treatment. The module includes PowerPoint presentations, teaching modules, and video vignettes that can be used to train hospital staff. Available as AHRQ Pub. No. 08-0074-CD in late 2008.
Available at http://teamstepps.ahrq.gov/index.htm or as AHRQ Pub. No. 06-0020.
Tools for Health Care Consumers
AHRQ materials help health care consumers work as
partners with their doctors, pharmacists, and nurses.
Check Your Medicines: Tips for Taking Medicines Safely. This checklist has questions patients should ask their doctors to help them take the right medicine in the right way at the right time. Available at http://www.ahrq.gov/consumer/checkmeds.htm or as AHRQ Pub. No. 07-M008-1.
Five Steps to Safer Health Care. This flyer explains what questions patients should ask their doctors about medicines, tests, procedures, surgery, and hospitals. Available at http://www.ahrq.gov/consumer/5steps.htm or as AHRQ Pub. No. 04-M005.
Having Surgery? What You Need to Know. This brochure lists questions patients should ask their doctors or nurses to better understand an upcoming surgery. Available at http://www.ahrq.gov/consumer/surgery/surgery.htm or as AHRQ Publication No. 05(06)-0074-A.
Your Guide to Coumadin®/Warfarin Therapy. This guide for patients explains what to expect while on Coumadin®/Warfarin therapy. Available at http://www.ahrq.gov/consumer/coumadin.htm or as AHRQ Pub. No. 08-0028-A (English) or 08-0028-B (Spanish).
Your Guide to Preventing and Treating Blood Clots. This guide for patients discusses ways to prevent, treat, and recognize symptoms of blood clots. It also describes medications used to prevent blood clots and their side effects. Available at http://www.ahrq.gov/consumer/bloodclots.htm or as AHRQ Pub. No. 08-0058-A (English) or 08-0058-B (Spanish).
Questions Are the Answer
Questions are the Answer:
This Web-based set of tools gets patients more engaged and involved in their health care by addressing topics and linking to AHRQ publications for consumers on:
- Reducing medical mistakes.
- Talking with clinicians.
- Getting medical tests.
- Planning for surgery.
- Getting a prescription.
The site helps patients to compile a list of questions to ask their health care provider or pharmacist during their next visit. Questions are grouped by topic areas to make it easy to create a personalized list of questions.
A printed version of the question list tool with space for answers, called Be Prepared for Medical
Appointments—Build Your Question List, is available from AHRQ as AHRQ Pub. No. 07-0039-A.
The Questions are the Answer site also provides non-AHRQ resources, a glossary, and 60- and 30-second
videos that were used in a national television campaign. Available at http://www.ahrq.gov/questionsaretheanswer/index.html.
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How to Get These Resources
These and more AHRQ resources are available online at http://www.ahrq.gov. Printed materials are available by calling AHRQ's Publications Clearinghouse at (800) 358-9295, or by sending an E-mail request with the title and publication number to ahrqpubs@ahrq.hhs.gov
AHRQ Publication No. 08-M070
Current as of September 2008
Internet Citation:
AHRQ Patient Safety Tools and Resources. AHRQ Publication No. 08-M070. September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pstools.htm
540 Gaither Road Rockville, MD 20850