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  Patient Safety/Medical Errors

Alternative OrderingPhone: 1-800-358-9295; Outside of the United States: 703-437-2078; TTY/TDD: 1-888-586-6340
Mail: AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547
 
  2008 Hospital Survey on Patient Safety Culture Comparative Database Report AHRQ 08-0039
Agency for Healthcare Research and Quality, February 2008, 77 pp. Updates the 2007 report and includes more data, including results from a total of 519 hospitals and 160,176 hospital staff respondents who completed the survey. Also includes a new chapter on trending tha presents results showing change over time for 98 hospitals that administered the survey and submitted data twice.  
 
Product Cost:  $0.00   EACH
 
  Advances in Patient Safety: From Research to Implementation AHRQ 05-0021-CD
Agency for Healthcare Research and Quality and U.S. Department of Defense, April 2005. Four-volume set covers new patient safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors and harm. CD-ROM Volumes 1-4.  
 
Product Cost:  $0.00   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches -- 2008 Update, CD AHRQ 08-0034-CD
Agency for Healthcare Research and Quality, August 2008. Searchable CD-ROM version of 4-volume set comprised of 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Also available in print as a 4-volume set (AHRQ 08-0034) or as individual volumes 1-4.  
 
Product Cost:  $1.25   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches, 2008 Update, Printed 4-volume set AHRQ 08-0034
Agency for Healthcare Research and Quality, August 2008. This 4-volume set comprises 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Single copies of the individual volumes 1-4 (AHRQ 08-0034-1, 08-0034-2, 08-0034-3, 08-0034-4) and a searchable CD-ROM (AHRQ 08-0034-CD) are also available.  
 
Product Cost:  $20.00   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches, 2008 Update, Volume 1: Assessment AHRQ 08-0034-1
Agency for Healthcare Research and Quality, August 2008. Volume 1 of a 4-volume set comprised of 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Available in print (single copies of 4-volume set or individual volumes available free) and as a searchable CD-ROM. (AHRQ 08-0034) CD-ROM Volumes 1-4 (AHRQ 08-0034-CD)  
 
Product Cost:  $5.00   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches, 2008 Update, Volume 2: Culture and Redesign AHRQ 08-0034-2
Agency for Healthcare Research and Quality, August 2008. Volume 2 of a 4-volume set comprised of 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Available in print (single copies of 4-volume set or individual volumes available free) and as a searchable CD-ROM. (AHRQ 08-0034) CD-ROM Volumes 1-4 (AHRQ 08-0034-CD)  
 
Product Cost:  $5.00   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches, 2008 Update, Volume 3: Performance and Tools AHRQ 08-0034-3
Agency for Healthcare Research and Quality, August 2008. Volume 3 of a 4-volume set comprised of 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Available in print (single copies of 4-volume set or individual volumes available free) and as a searchable CD-ROM. (AHRQ 08-0034) CD-ROM Volumes 1-4 (AHRQ 08-0034-CD)  
 
Product Cost:  $5.00   EACH
 
  Advances in Patient Safety: New Directions and Alternative Approaches, 2008 Update, Volume 4: Technology and Medication Safety AHRQ 08-0034-4
Agency for Healthcare Research and Quality, August 2008. Volume 4 of a 4-volume set comprised of 115 articles that present new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools for improving patient safety. Available in print (single copies of 4-volume set or individual volumes available free) and as a searchable CD-ROM. (AHRQ 08-0034) CD-ROM Volumes 1-4 (AHRQ 08-0034-CD)  
 
Product Cost:  $5.00   EACH
 
  Adverse Event Reporting Systems and Safer Healthcare AHRQ 09-R043
J. Battles, D. Stevens, Quality and Safety in Health Care 18(1):February 2009, 2. Editorial discusses the potential of adverse event reporting systems to improve patient safety and the slow progress that has been made thus far in implementing such systems.  
 
Product Cost:  $0.00   EACH
 
  Adverse-event-reporting Practices by US Hospitals: Results of a National Survey. AHRQ 09-R021
D. Farley, A. Haviland, S. Champagne, et al., Quality and Safety in Health Care, 17(6):December 2008, 416-423. Reports on the results of a national survey of 2,050 non-Federal U.S. hospitals that gathered baseline data on the characteristics of systems and processes the hospitals were using for adverse event reporting for use in assessing improvement in reporting.  
 
Product Cost:  $0.00   EACH
 
  Becoming an High Reliability Organization Operational Advice for Hospital Leaders AHRQ 08-0022
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.  
 
Product Cost:  $0.00   EACH
 
  CMS's Hospital-Acquired Condition Lists Link Hospital Payment, Patient Safety AHRQ 09-R054
C. Clancy, American Journal of Medical Quality 24(2):March/April 2009, 166-168. Commentary discusses the Centers for Medicare & Medicaid Services change in policy that denies hospital payment for certain preventable adverse events that are the result of the hospital?s care and the policy implications of this change, as well as its potential for quality improvement.  
 
Product Cost:  $0.00   EACH
 
  Designing for Safety: Evidence-Based Design and Hospitals AHRQ 08-R035
C. Clancy, American Journal of Medical Quality, 23(1):January/February 2008, 66-69. discusses how evidence-based design principles can contribute to safer care for hospitalized patients.  
 
Product Cost:  $0.00   EACH
 
  Do Patient Safety Events Increase Readmissions? AHRQ 09-R051
B. Friedman, W. Encinosa, H. Jiang, et al., Medical Care 47(5):May 2009, 583-590. Examines the effects of adverse safety events in the hospital on risks of deaths and readmissions.  
 
Product Cost:  $0.00   EACH
 
  DoD Medical Team Training Programs: An Independent Case Study Analysis. AHRQ 06-0001
Companion to Medical Teamwork and Patient Safety: The Evidence-Based Relation. 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.  
 
Product Cost:  $0.00   EACH
 
  Establishing a Global Learning Community for Incident-Reporting Systems AHRQ 11-R018
J. Pham, S. Gianci, J. Battles, et al., Quality and Safety in Health Care, October 2010; 19(5):446-451. Offers guidance through a presentation of expert discussions about methods to identify, analyze, and prioritize incidents, mitigate hazards, and evaluate risk reduction.  
 
Product Cost:  $0.00   EACH
 
  Evidence Shows Cost and Patient Safety Benefits of Emergency Pharmacists AHRQ 08-R080
C. Clancy, American Journal of Medical Quality, 23(3):May/June 2008, 231-233. Discusses the role of emergency pharmacists in hospital emergency care settings, the effects on reducing adverse drug events , cost savings, and staff acceptance, as well as suggestions for implementing emergency pharmacist programs.  
 
Product Cost:  $0.00   EACH
 
  Forging a New Path to Medication Safety With Emergency Pharmacists AHRQ 08-R055
C. Clancy, Journal of Patient Safety, 4(1):March 2008, 1-2. Invited commentary that discusses the emergence of the emergency pharmacist and two new initiatives to assist pharmacists and hospitals in getting support for and implementing emergency pharmacist programs.  
 
Product Cost:  $0.00   EACH
 
  Frontline Hospital Workers and the Worker Safety/Patient Safety Nexus AHRQ 13-R059
R. Sokas, B. Braun, L. Chenvens, et al., The Joint Commission Journal on Quality and Patient Safety, 39(4):2013, 185-192. Reports on a 2012 conference exploring whether and how hospital-based frontline health care workers affect patient safety and how they experience safety in their work settings.  
 
Product Cost:  $0.00   EACH
 
  Guide for Developing a Community-Based Patient Advisory Council AHRQ 08-0048
Agency for Healthcare Research and Quality, March 2008, 50 pp. Provides information and guidance that individuals and organizations can use to develop community-based advisory councils to bring about improvements in patient safety through education, collaboration, and consumer engagement.  
 
Product Cost:  $0.00   EACH
 
  Hospital Survey on Patient Safety Culture 2009 Comparative Database Report. AHRQ 09-0030
Agency for Healthcare Research and Quality, March 2009, 92 pp. Updates the 2008 report and includes results from 622 hospitals and nearly 200,000 hospital staff respondents, as well as a chapter on trending with results from hospitals that administered the survey multiple times.  
 
Product Cost:  $0.00   EACH
 
  Hospital Survey on Patient Safety Culture. AHRQ 04-0041
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.  
 
Product Cost:  $0.00   EACH
 
  Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. HSOPS Benchmarking Databook AHRQ 07-0025
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.  
 
Product Cost:  $0.00   EACH
 
  Hospital Survey on Patient Safety Culture: 2010 Comparative Database Report AHRQ 10-0026
Agency for Healthcare Research and Quality, March 2010, 85 pp. Updates the 2009 report and presents results from 885 hospitals and 338,607 hospital staff respondents, as well as a chapter on trending that presents results showing change over time for 321 hospitals that submitted survey data more than once.  
 
Product Cost:  $0.00   EACH
 
  How Often are Potential Patient Safety Events Present on Admission? AHRQ 08-R069
R. Houchens, A. Elixhauser, P. Romano, Joint Commission Journal on Quality and Patient Safety, 34(3):March 2008, 154-163. Evaluates the use of information on whether diagnoses are present at the time of hospital admission to assess the face validity of present-on-admission (POA) information in two States?California and New York, evaluates the relationship between POA information and the AHRQ Patient Safety Indicators (PSIs), and examines the extent to which the PSIs defined without POA information are valid measures of hospital-level quality of care.  
 
Product Cost:  $0.00   EACH

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