Innovations To Improve Patient Safety | AHRQ Health Care Innovations Exchange

Innovations To Improve Patient Safety | AHRQ Health Care Innovations Exchange

Innovations To Improve Patient Safety Wednesday, May 18, 2016

This issue of the Innovations Exchange is the last in our monthly series focused on health care disparities experienced by different racial, ethnic, and socioeconomic groups in the U.S. population.

Each year since 2003, the Agency for Healthcare Research and Quality has produced the National Healthcare Quality Report and the National Healthcare Disparities Report. Beginning with the 2014 reports, findings on health care quality and health care disparities are integrated into a single document. The National Healthcare Quality and Disparities Report (QDR) provides a comprehensive overview of the quality of care received by the general U.S. population and health care disparities. Detailed information on individual measures and specific populations is available through a series of chartbooks.

In March 2016, AHRQ released the Chartbook on Patient Safety, which summarizes trends across measures of patient safety from the QDR, both overall and for populations defined by age, sex, race, ethnicity, income, and other characteristics. The chartbook includes information about patient safety measures in hospitals, ambulatory care, nursing homes, and home health.  

The Innovations Exchange collection contains many Innovation Profiles and QualityTools aimed at improving patient safety across a range of health care settings. This issue features a selection of content related to preventing adverse healthcare-associated conditions and harm from care.

To learn how AHRQ-supported evidence makes health care safer, visit AHRQ Views to read blog posts by AHRQ leaders about Strengthening AHRQ’s Role in Preventing Medical Errorsand how AHRQ Supports Hospitals As They Make Care Safer.

Featured Innovations:

• Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
• Emergency Department and Urgent Care Clinicians Use Protocol To Reduce Opioid Prescriptions for Patients Suspected of Abusing Controlled Substances
• 24-Hour Inpatient Pulse Oximetry Monitoring Reduces Rescue Events and Intensive Care Unit Transfers
• Checklists With Medication Vest or Sash Reduce Distractions During Medication Administration
• Comprehensive Hospital Program Significantly Reduces Clostridium difficile Infections
• Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
• Six-Sigma Inspired Workflow Redesign Leads to Better Adherence to Evidence-Based Protocols and Fewer Infections for Surgery Patients
• Multiple Safeguards in Hospital Intravenous Medication Administration Processes Reduces Dosing Limit Violations and Improves Nurse Efficiency
• Checklist-Plus-Technology System Eliminates Wrong-Site Surgery and Near-Misses, Enhances Required Preoperative Process Compliance
• Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
• Round-the-Clock Intensivists Eliminate Ventilator-Associated Pneumonia, Central Line Infections, and Pressure Ulcers in Intensive Care Unit
• Adaptation and Expansion of Existing Bundle of Inpatient Interventions Reduces Ventilator-Associated Pneumonia at Long-Term Care Facility
• State-Mandated Tracking and Public Reporting Reduce Incidence and Costs of Common Hospital-Acquired Infections
• Interdisciplinary Team Identifies and Addresses Risk Factors for Falls Among Nursing Home Residents, Leading to Fewer Falls and Less Use of Restraints
• Multihospital System Uses Proactive Screening, Algorithms, and Tools To Improve Sepsis Care, Leading to More Appropriate Care and Better Outcomes
• Comprehensive Program to Change Hand Hygiene Culture Improves Adherence to Disinfection Guidelines, Leading to Lower Infection Rates and Costs

Featured QualityTools:

• Chartbook on Patient Safety
• Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) Tools and Materials
• Comprehensive Unit-Based Safety Program Toolkit
• Hospital Survey on Patient Safety Culture
• Medical Office Survey on Patient Safety Culture
• Nursing Home Survey on Patient Safety Culture
• Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change
• Ambulatory Patient Safety Toolkit