Accidental Iatrogenic Pneumothorax in
Hospitalized Patients. C. Zhan, M. Smith, D. Stryer, Medical
Care 44(2): February 2006, 182-186. Assesses the risk for accidental
iatrogenic pneumothorax in patients hospitalized with specific diagnoses who
underwent specific procedures. (AHRQ 06-R029)
Advances in Patient Safety: From Research to
Implementation. Agency for Healthcare Research and Quality and
U.S. Department of Defense, April 2005. Four-volume set on CD-ROM covers new
patient safety findings, investigative approaches, process analyses, and
practical tools for preventing medical errors and harm.
CD-ROM—Volumes 1-4 (AHRQ 05-0021-CD)
Agency for Healthcare Research and Quality's
National Quality and Disparities Reports Emphasize Patient
Safety. C. Clancy, D. McNeill, E. Moy, et al., Journal of
Patient Safety 2(2): June 2006, 70-71. Commentary reviews the
implications of the National Quality and Disparities Reports for patient
safety. Reports focus attention on patient safety and offer a set of measures
that provide useful trend information and comparative data. (AHRQ 07-R013)
AHRQ WebM&M. Agency for
Healthcare Research and Quality, March 2003, two-fold brochure. Describes a
Web-based patient safety resource that incorporates a peer-reviewed journal.
Site includes descriptions of specific cases of medical errors and patient
safety problems, commentaries, a users' forum, and links to other patient
safety resources. (AHRQ 03-0014)
Ambulatory Care Visits for Treating Adverse
Drug Effects in the United States, 1995-2001. C. Zhan, I. Arispe,
E. Kelley, et al., Joint Commission Journal on Quality and Patient
Safety 31(7): July 2005, 372-378. Explores the use of existing
national surveys and ICD-9-CM codes for ambulatory visits for adverse drug
effects to assess national prevalence of adverse drug effects. (AHRQ
05-R067)
Becoming a High Reliability Organization:
Operational Advice for Hospital Leaders. Agency for Healthcare
Research and Quality, February 2008, 36 pp. Discusses five key high
reliability concepts and tools that a growing number of hospitals are using to
help achieve their safety, quality, and efficiency goals to improve patient
safety and care. Key concepts include sensitivity to operations, reluctance to
simplify, preoccupation with failure, deference to expertise, and resilience.
(AHRQ 08-0022)
Care Transitions: A Threat and an Opportunity
for Patient Safety. C. Clancy, American Journal of Medical
Quality 21(6): November/December 2006, 415-417. Discusses the pros
and cons of using medical teams to reduce errors and ways to make safer
patient handoffs from one care setting to another. (AHRQ 07-R026)
Communication Failure: Basic Components,
Contributing Factors, and the Call for Structure. E. Dayton, K.
Henriksen, Joint Commission Journal on Quality and Patient Safety
33(1): January 2007, 34-47. Discusses the role of communication failures in
medical errors and how more structured and explicitly designed forms of
communication could reduce ambiguity and enhance clarity in health care
settings. (AHRQ 07-R049)
Cost-Effective Enhancement of Claims Data to
Improve Comparisons of Patient Safety. H. Jordan, M. Pine, A.
Elixhauser, et al., Journal of Patient Safety 3(2): June 2007, 82-90.
Describes AHRQ's Patient Safety Indicators and how they can be used in
conjunction with clinical data as a tool to screen for medical errors. (AHRQ
07-R063)
DoD Medical Team Training Programs: An
Independent Case Study Analysis. Agency for Healthcare Research
and Quality and Department of Defense, May 2006, 57 pp. Describes results of
an evaluation of three Department of Defense-sponsored medical team training
programs. (AHRQ 06-0001) Companion to Medical Teamwork and Patient Safety:
The Evidence-Based Relation (AHRQ 06-0053)
Evaluating the Patient Safety Indicators: How
Well Do They Perform on Veterans Health Administration Data? A.
Rosen, P. Rivard, S. Zhao, et al., Medical Care 43(9): September
2005, 873-884. Examines differences between observed and risk-adjusted Patient
Safety Indicator (PSI) rates in the Veterans Health Administration (VA),
compared to VA and non-VA PSI rates, and investigates the construct validity
of the PSIs by examining correlations of the PSIs with other outcomes of VA
hospitals. (AHRQ 06-R012)
First, Do No Harm: Reducing Pediatric
Medication Errors. R. Hughes, E. Edgerton, American Journal
of Nursing 105(5): May 2005, 36-42. Discusses the frequency of
pediatric medication errors, the unique vulnerabilities of children, and the
disproportional reliance on ambulatory care as compared to inpatient care.
(AHRQ 05-R052)
Hospital Finances and Patient Safety
Outcomes. W. Encinosa, D. Bernard, Inquiry 42: Spring
2005, 60-72. Using the Healthcare Cost and Utilization Project (HCUP) State
Inpatient Data for Florida from 1996 to 2000, examines whether financial
pressure at hospitals is associated with increases in the rate of patient
safety events for major surgeries. (AHRQ 05-R070)
Hospital Survey on Patient Safety
Culture. Agency for Healthcare Research and Quality, September
2004, 75 pp. Includes a review of the literature pertaining to safety issues,
accidents, medical errors, error reporting, and the safety climate of hospital
environments. The final survey was pilot tested with more than 1,400 hospital
employees across the United States, and includes information on sample group
selection, data collection, and interpreting results. (AHRQ 04-0041)
Hospital Survey on Patient Safety Culture:
2007 Comparative Database Report. Agency for Healthcare Research
and Quality, April 2007, 102 pp. Presents statistics on the patient safety
culture areas or composites assessed in the Hospital Survey on Patient Safety
Culture and averages for breakouts of the data by hospital and respondent
characteristic. Allows hospitals to compare their data with data from other
similar hospitals. (AHRQ 07-0025)
The Importance of Safety and Quality in Rural
America. H. Burstin, M. Wakefield, Journal of Rural
Health 20(4): October 2004, 301-303. Introduction to a special issue
that draws much-needed research attention to the topic of rural health care
quality and attempts to stimulate appropriate redesign in rural health care
systems and practices through institutional, academic, and public policy
change. (AHRQ 05-R043)
Improving Patient Safety by Instructional
Systems Design. J. Battles, Quality and Safety in Health
Care 15(Suppl 1):2006, 25-29. Discusses how patient safety training
itself sometimes contributes to the risks and hazards of health care
associated injuries. Examines the principle of safety by design and the
application of established design principles to patient safety education and
training programs. (AHRQ 07-R044)
Improving Patient Safety—Five Years
After the IOM Report. D. Altman, C. Clancy, R. Blendon, New
England Journal of Medicine 351(20): November 11, 2004, 2041-2043.
Discusses the state of improving patient safety in hospitals after a 1999
report from the Institute of Medicine featured statistics about preventable
medical errors. (AHRQ 05-R017)
Improving Patient Safety in Hospitals:
Contributions of High-Reliability Theory and Normal Accident
Theory. M. Tamuz, M. Harrison, Health Services Research
Part II, 41(4): August 2006, 1654-1676. Identifies the distinctive
contributions of high-reliability theory and normal accident theory as
frameworks for examining five patient safety practices. (AHRQ 06-R076)
Improving the Complex Nature of Care
Transitions. R. Hughes, C. Clancy, Journal of Nursing Care
Quality 22(4):2007, 289-292. Discusses the potential for medical
errors associated with shift handovers and patient transfers, presents
findings from some recent studies focused on patient transitions, and
identifies remaining challenges in this area. (AHRQ 08-R014)
Improving the Health Care Work Environment: A
Sociotechnical Systems Approach. M. Harrison, K. Henriksen, R.
Hughes, Joint Commission Journal on Quality and Patient Safety 33(11
Suppl): November 2007, 3-6. Discusses the use of a sociotechnical systems
approach to improve the health care work environment and introduces a special
journal supplement on this topic. (AHRQ 08-R022)
Improving the Health Care Work Environment:
Implications for Research, Practice, and Policy. M. Harrison, K.
Henriksen, R. Hughes, Joint Commission Journal on Quality and Patient
Safety 33(11 Suppl): November 2007, 81-84. Discusses how physical
settings and conditions—such as room layout, light, and
noise—interact with the organization and delivery of health care and
explains how the physical environment directly and indirectly affects
patients' care outcomes and practitioners' behavior and well-being. (AHRQ
08-R026)
Initiating Transformational Change to Enhance
Patient Safety. K. Henriksen, M. Keyes, D. Stevens, et al.,
Journal of Patient Safety 2(1): March 2006, 20-24. Explores what
transformational change means with respect to patient safety and quality
initiatives and examines lessons learned as found in the management and
transformation change literature. (AHRQ 07-R003)
The Intensive Care Unit, Patient Safety, and
the Agency for Healthcare Research and Quality. C. Clancy,
American Journal of Medical Quality 21(5): September-October 2006,
348-351. Highlights some of the major issues in intensive care unit safety,
including difficult working conditions that make errors more probable, and
describes AHRQ-supported research and other activities in the patient safety
area. (AHRQ 07-R001)
Keeping Our Promises: Research, Practice, and
Policy Issues in Health Care Reliability; Foreword to a Special Issue of
Health Services Research. J. Reinertsen, C. Clancy, Health
Services Research 41(4): August 2006, 1535-1538. Introduces a special
journal issue focused on an organizational approach to patient safety,
including articles on research and policy issues in reliability,
organizational culture, and translation of reliability theory into practice.
(AHRQ 06-R074)
Medicaid Markets and Pediatric Patient Safety
in Hospitals. R. Smith, R. Cheung, P. Owens, et al., Health
Services Research 42(5): October 2007, 1981-1997. Compares the
association between Medicaid market characteristics and the occurrence of
potentially preventable adverse medical events in hospitalized children in
Florida, New York, and Wisconsin in the years 1999-2001. (AHRQ 08-R018)
Medical Teamwork and Patient Safety: The
Evidence-Based Relation. Agency for Healthcare Research and
Quality, April 2005, 59 pp. Presents evidence to support the relation between
team training and patient safety. Presents background information related to
teamwork, including the nature of effective teamwork, teamwork-related
knowledge, skills, and attitudes, and contextual issues surrounding teamwork.
(AHRQ 05-0053)
Medicare Payment for Selected Adverse Events:
Building the Business Case for Investing in Patient Safety. C.
Zhan, B. Friedman, A. Mosso, et al., Health Affairs
25(5): September/October 2006, 1386-1393. Provides insights into the intricate
financial relationships surrounding adverse events and illustrates the
business cases for both Medicare and hospitals to invest in patient safety.
(AHRQ 07-R008)
Medication Errors: Why They Happen and How
They Can Be Prevented. R. Hughes, E. Ortiz, American Journal
of Nursing Supplement: March 2005, 14-24. Provides an overview of
what is known about errors in medication administration, barriers to
implementing safer practices, and current and potential mechanisms to improve
medication administration. (AHRQ 05-R044)
Mistake-Proofing in Health Care: Lessons for
Ongoing Patient Safety Improvements. C. Clancy, American
Journal of Medical Quality 22:2007, 463-465. Discusses the role and
importance of mistake-proofing in creating a culture of patient safety in
health care organizations. (AHRQ 08-R016)
Mistake-Proofing the Design of Health Care
Processes. Agency for Healthcare Research and Quality, May 2007,
155 pp. Provides an in-depth introduction to mistake-proofing, a little-known
but very promising approach to preventing medical errors and reducing the
adverse events that result from errors.
CD-ROM. May 2007
(07-0020-CD)
Report. May 2007 (AHRQ 07-0020).
Nurses'Working Conditions: Implications for
Infectious Disease. P. Stone, S. Clarke, J. Cimiotti, et al.,
Emerging Infectious Diseases 10(11): November 2004, 1984-1989.
Discusses the nurse workforce, reviews research examining nursing as it
relates to infectious disease, identifies gaps in the literature, and
discusses potential policy options. (AHRQ 05-R006)
Organizational Silence and Hidden Threats to
Patient Safety. K. Henriksen, E. Dayton, Health Services
Research Part II, 41(4): August 2006, 1539-1554. Focuses on some of
the less obvious factors contributing to organizational silence—a
collective-level phenomenon of saying or doing very little in response to
significant problems that face an organization—that can threaten patient
safety. (AHRQ 06-R060)
Patient Safety Improvement Corps: Tools,
Methods, and Techniques for Improving Patient Safety. Agency for
Healthcare Research and Quality and Department of Veterans Affairs, August
1007. A DVD that provides a self-paced, modular approach to training
individuals involved in patient safety activities at the institutional level.
The DVD presents eight modules that depict processes and tools that can be
used to develop a systems-based approach to patient safety including:
investigation of medical errors and their root causes; identification,
implementation, and evaluation of system-level interventions to address
patient safety concerns; and steps necessary to promote a culture of safety
within a hospital or other health care facility. (AHRQ 07-0035-DVD)
Patient Safety in Nursing Practice.
M. Farquhar, B. Sharp, C. Clancy, AORN Journal 86(3(): September
2007, 455-457. Discusses AHRQ-supported research focused on the role of nurses
in improving patient safety and quality of care. (AHRQ 08-R019)
Patient Safety in the Intensive Care Unit:
Challenges and Opportunities. C. Clancy, Journal of Patient
Safety 3(1): March 2007, 6-8. Commentary on the occurrence of errors
in hospital ICUs, as well as examples of research in this area funded by the
Agency for Healthcare Research and Quality. (AHRQ 07-R054)
Problems and Prevention: Chest Tube
Insertion. Agency for Healthcare Research and Quality and
University of Maryland School of Medicine, September 2006, 11-minute DVD. Uses
video excerpts of 50 actual chest tube insertion procedures to illustrate
problems that can occur and provides correct techniques for inserting chest
tubes. (AHRQ 06-0069-DVD)
Putting the Patient in Patient
Safety. C. Clancy, Journal of Patient Safety 3(2): June
2007, 65-66. Discusses the importance of patient participation in health care
decisionmaking as one of the key factors in reducing medical errors and
improving patient safety. (AHRQ 07-R076)
Relationship Between Performance Measurement
and Accreditation: Implications for Quality of Care and Patient
Safety. M. Miller, P. Pronovost, M. Donithan, et al.,
American Journal of Medical Quality 20(5): September/October 2005,
239-252. Examines the association between the Joint Commission on
Accreditation of Healthcare Organizations accreditation scores and the AHRQ's
Inpatient Quality Indicators and Patient Safety Indicators. (AHRQ 06-R005)
Sensemaking of Patient Safety Risks and
Hazards. J. Battles, N. Dixon, R. Borotkanics, et al., Health
Services Research Part II, 41(4): August 2006, 1555-1575. Defines
patient safety sensemaking in the context of eliminating risks and hazards
that are a threat to patient safety and discusses it as a conceptual
framework. (AHRQ 06-R059)
Sleepless in the Hospital: Evidence Mounts
that Tired Caregivers May Compromise Quality. C. Clancy,
Journal of Patient Safety 3(3): September 2007, 125-126. Comments on
recent evidence on the relationship between extra long shifts without sleep
for residents and interns and the occurrence of preventable adverse events in
hospitals. (AHRQ 08-R007)
Struggling to Invent High-Reliability
Organizations in Health Care Settings: Insights from the Field.
N. Dixon, M. Shofer, Health Services Research Part II, 41(4): August
2006, 1618-1632. Discusses an analysis of findings from an AHRQ consumer needs
assessment of leaders in selected health care systems, asking questions about
current implementation initiatives and perceived needs for continued
implementation of patient safety initiatives. (AHRQ 06-R075)
TeamSTEPPS: Assuring Optimal Teamwork in
Clinical Settings. C. Clancy, D. Tornberg, American Journal
of Medical Quality 22(3): May/June 2007, 214-217. Discusses the
importance of teamwork in promoting high quality health care and preventing
medical errors and describes the Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) training resource, which is
sponsored jointly by AHRQ and the Department of Defense. (AHRQ 07-R024)
TeamSTEPPS: Optimizing Teamwork in the
Perioperative Setting. C. Clancy, AORN Journal
86(1):2007, 18-22. Discusses the importance of teamwork in health care and
describes the TeamSTEPPS initiative, which is a resource for training health
care providers in better teamwork practices. The program was developed jointly
by AHRQ and the Department of Defense. (AHRQ 08-R001)
Tracking Rates of Patient Safety Indictors
Over Time: Lessons from the Veterans Administration. A. Rosen, S.
Zhao, P. Rivard, et al., Medical Care 44(9): September 2006, 850-861.
Provides a descriptive analysis of the incidence of Patient Safety Indicator
(PSI) events from 2001 to 2004 in the Veterans Health Administration, examines
trends in national PSI rates at the hospital discharge level over time, and
assesses whether hospital characteristics and baseline safety-related hospital
performance predict future hospital stay-related performance. (AHRQ
06-R078)
Training Health Care Professionals for
Patient Safety. C. Clancy, American Journal of Medical
Quality 20(5): September/October 2005, 277-279. Discusses AHRQ's
goals, vision, and role in ongoing professional education and staff training
to foster a new culture of patient safety. (AHRQ 06-R006)
Transforming Hospitals: Designing for Safety
and Quality DVD. Agency for Healthcare Research and Quality,
September 2007. Reviews the case for evidence-based hospital design and how it
can increase patient and staff satisfaction and safety, quality of care, and
employee retention, as well as how it results in a positive return on
investment. Describes the experiences of three modern hospitals that
incorporated evidence-based design elements into their construction and
renovation projects. (AHRQ 07-0076-DVD)
Using Standardised Patients in an Objective
Structured Clinical Examination as a Patient Safety Tool. J.
Battles, S. Wilkinson, S. Lee, Quality & Safety in Health Care
13(Suppl 1):2004, i46-i50. Describes how using individuals who have been
trained to portray a medical case in a consistent manner can be a powerful
tool in measuring continued competence in human reliability and skill
performance where such skills are a critical attribute to maintaining patient
safety. (AHRQ 05-R027)
TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient
Safety
Agency for Healthcare Research and Quality and Department of Defense,
September 2006. A comprehensive set of ready-to-use materials and training
curricula for health care organizations provides techniques to improve the
ability of teams to respond quickly and effectively to high-stress
situations.
Instructor Guide. 794 pp., explains
how to conduct a pre-training assessment of an organization's training needs,
how to present the information effectively, and how to manage organizational
change. Includes printed materials in a 3-inch loose-leaf binder, plus the
Multimedia Resource Kit and the Pocket Guide. (AHRQ
06-0020-0; single copies $12.00 for shipping to addresses within the U.S.)
Multimedia Resource Kit. Includes
contents of the Instructor Guide and the Pocket Guide as
printable files (Word®, PDF, and PowerPoint®), plus a DVD that
contains nine video vignettes. (AHRQ 06-0020-3; single copies free)
Pocket Guide. Spiral-bound, 36 pp.,
summarizes TeamSTEPPS™ principles in a portable, easy-to-use format. (AHRQ
06-0020-2; single copies free)
Poster. 17 x 22 inch, tells your
staff you are adopting TeamSTEPPS™ (AHRQ 06-0020-5; single copies free)
AHRQ Publications Order Form
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