Provider Resources
The following resources can help healthcare professionals improve the safety and quality of services to patients.
Infection Prevention
Monograph: Preventing Central Line-Associated Infections: A Global Challenge, A Global Perspective
The Joint Commission, May 2012
Quality Indicators
AHRQ Quality Indicators Toolkit for Hospitals: Improving Performance on the AHRQ Quality Indicators
Agency for Healthcare Research and Quality, November 2011
A toolkit to help hospitals understand AHRQ’s quality indicators and use them to improve quality and patient safety.
Communication
Words to Watch (National Patient Safety Foundation)
Many patients have trouble understanding words used by doctors and in healthcare institutions. This fact sheet provides a quick reference of words that patients struggle to understand and possible alternatives.
Taking Care of Myself: A Guide for When I Leave the Hospital (Agency for Healthcare Research & Quality)
An easy-to-read guide that can be used by both hospital staff and patients during the discharge process; provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.
Inpatient Facilities
Rapid Response Teams
Rapid response teams play an important role in advancing patient safety by increasing the early detection of patients in trouble and identifying opportunities to prevent adverse events. The Institute for Healthcare Improvement describes the importance of establishing a rapid response team and provides a practical approach for getting started.
Pharmacy
Advancing Pharmacy Health Literacy Practices Through Quality Improvement: Curricular Modules for Faculty
Agency for Healthcare Research and Quality, December 2011
A set of modules to help pharmacy faculty integrate health literacy and health literacy quality improvement into courses, experiential education, and projects for PharmD students and pharmacy residents.
List of Confused Drug Names (Institute for Safe Medicine Practices)
A resource to help pharmacists determine when special precautions are needed to avoid medication mix-ups.
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (Agency for Healthcare Research & Quality)
This toolkit provides a step-by-step guide to improving the medication reconciliation process. The MATCH toolkit aides evaluation of the effectiveness of an existing medication reconciliation process and the identification and response to any gaps; emphasizes standardization of the process for doctors, nurses, and pharmacists within the facility to document and confirm a patient’s home medication list upon admission; and also emphasizes the need to clearly define roles and responsibilities of clinical staff.
Surgery
Preventing Wrong-Site Surgery (Pennsylvania Patient Safety Authority)
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process.
Recent Research
Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report
Agency for Healthcare Research and Quality, February 2012
“Based on data from 1,128 U.S. hospitals, the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report provides initial results that hospitals can use to compare their patient safety culture to other U.S. hospitals. In addition, the 2012 report presents results showing change over time for 650 hospitals that submitted data more than once.”
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Hospital Incident Reporting Systems Do Not Capture Most Patient Harm
Department of Health and Human Services, Office of Inspector General, January 2012
This new study found that hospital employees are only reporting fourteen percent of all medical errors and usually don’t change their practices to prevent future harm to patients. The study was based on an independent review of patient records.
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Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011
The Commonwealth Fund Commission on a High Performance Health System, October 2011
Updating a series of comprehensive assessments of U.S. population health and health care quality, access, efficiency, and equity, this research offers information related to quality and patient safety and their relationship to health reform. The report highlights inefficiency and inequitable care as key concerns, which are important aspects and focus areas for building a culture of patient safety.
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Research in Ambulatory Patient Safety 2000–2010: A 10-Year Review
American Medical Association, 2011
This report details ten years of research on ambulatory safety. In summary, the report concludes that “Though some very high-quality work on ambulatory safety took place between 2000 and 2010, research and initiatives in ambulatory safety were remarkably limited, both in quantity and in the ability to generalize from the studies that were reported.”
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Ambulatory Surgery Facilities: A Comprehensive Review of Medication Error Reports in Pennsylvania
Pennsylvania Patient Safety Authority, September 2011
The Pennsylvania Patient Safety Authority offers insight into adverse medication events in the ambulatory surgery setting through the analysis of reported events. The article reviews the most common types of medication events, patient populations involved, medications involved, and event descriptions to determine specific and common issues affecting this setting. In addition, risk reduction strategies to improve patient safety are discussed.
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Variations in Amenable Mortality—Trends in 16 High-Income Nations
Health Policy, September 12, 2011
The rate of “mortality amenable to health care”—that is, deaths that are considered preventable with timely and effective health care—declined for people under age 75 across 16 high-income nations between 1997–1998 and 2006–2007. While all countries showed improvement, the United States improved the least.
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Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report
Agency for Healthcare Research and Quality, August 2011
“Based on data from 226 nursing homes in the United States, the Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report provides initial results that nursing homes can use to compare their patient safety culture to other U.S. nursing homes.”
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‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured
Health Affairs, April 2011
This study compared three methods to detect adverse events in hospitalized patients and found that adverse event detection methods commonly used in the United States fared poorly compared to other methods and that reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.
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Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries
Department of Health and Human Services, Office of Inspector General, November 2010
The Office of Inspector General estimates the national incidence of adverse events for hospitalized Medicare beneficiaries, assesses the preventability of such events, and estimates associated costs to Medicare.
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