Overview of AHRQ Resources Overview of AHRQ Resources to Improve Patient Safety to Improve Patient Safety

September 15, 2009September 15, 2009

Overview & IntroductionOverview & Introduction– Jeff Brady, M.D., AHRQ, CQuIPSJeff Brady, M.D., AHRQ, CQuIPS

SpeakersSpeakers

– Erin Hartman, M.S., University of California, San Erin Hartman, M.S., University of California, San FranciscoFrancisco

– Jim Battles, Ph.D., AHRQ, CQuIPSJim Battles, Ph.D., AHRQ, CQuIPS

– Greg Maynard, M.D., University of California, San DiegoGreg Maynard, M.D., University of California, San Diego

– Kerm Henriksen, Ph.D., AHRQ, CQuIPSKerm Henriksen, Ph.D., AHRQ, CQuIPS

– Farah Farah Englert, AHRQ, OCKTEnglert, AHRQ, OCKT

AgendaAgenda

To Err is Human: To Err is Human: Building a Safer Health SystemBuilding a Safer Health System

44,000 – 98,000 deaths/yr 44,000 – 98,000 deaths/yr

88thth leading cause of death in US leading cause of death in US

National Costs: $17 to $29 billionNational Costs: $17 to $29 billion

$2 billion Adverse Rx event costs $2 billion Adverse Rx event costs alonealone– 2% hospital admissions 2% hospital admissions

(preventable)(preventable)

– Add $4,700 in costs to each Add $4,700 in costs to each hospitalization hospitalization

Institute of Medicine, 1999Institute of Medicine, 1999

Personal Experience with Personal Experience with Medical ErrorsMedical Errors

Public (2004)

No65%

Yes34%

Don't Know

1%

Physicians (2002)

No65%

Yes35%

The percentage who said they have been personally involved The percentage who said they have been personally involved in a situation where a preventable medical error was made in in a situation where a preventable medical error was made in their owntheir own medical care or that of a medical care or that of a familyfamily member? member?

(Source: Kaiser Family Foundation surveys) (Source: Kaiser Family Foundation surveys)

AHRQ’s MissionAHRQ’s Mission

Improve the quality, safety, Improve the quality, safety, efficiency and effectiveness of efficiency and effectiveness of health care for all Americanshealth care for all Americans

Patient Safety PortfolioPatient Safety Portfolio

To improve the quality of care To improve the quality of care delivered to patients by decreasing delivered to patients by decreasing or eliminating health care risks and or eliminating health care risks and harms.harms.

– Increased emphasis on implementationIncreased emphasis on implementation

– Continued investment in researchContinued investment in research

AHRQ AHRQ Core Business AreasCore Business Areas

Creation of KnowledgeCreation of Knowledge

Synthesis and Dissemination Synthesis and Dissemination

Implementation and Use Implementation and Use

AHRQ Patient Safety BudgetAHRQ Patient Safety Budget

* Projected

0

10

20

30

40

50

60

Millions

2000 2002 2004 2006 2008 2010

Fiscal Year

Patient Safety Portfolio: Patient Safety Portfolio: Broad Areas of EmphasisBroad Areas of Emphasis

1.1. Create new knowledge about safe practices and Create new knowledge about safe practices and optimal structure for care. optimal structure for care.

2.2. Build research capacity by stabilizing upstream Build research capacity by stabilizing upstream investment to keep the research pipeline flowing. investment to keep the research pipeline flowing.

3.3. Address methodological and core scientific Address methodological and core scientific questions – e.g., questions – e.g., Evidence Report on Patient Safety Evidence Report on Patient Safety PracticesPractices. .

4.4. Disseminate patient safety products effectively for Disseminate patient safety products effectively for implementation. implementation.

5.5. Continue to engage in field-based partnerships (HAI Continue to engage in field-based partnerships (HAI ACTION)ACTION)

6.6. Seize opportunities for national implementation of Seize opportunities for national implementation of safe practicessafe practices

AHRQ Patient Safety AHRQ Patient Safety ResourcesResources

AHRQ PSNetAHRQ PSNet AHRQ WebM&MAHRQ WebM&M TeamSTEPPS™: Creating a safety Net for Healthcare TeamSTEPPS™: Creating a safety Net for Healthcare

OrganizationOrganization TeamSTEPPS™: Rapid Response System ModuleTeamSTEPPS™: Rapid Response System Module Hospital Survey on Patient Safety CultureHospital Survey on Patient Safety Culture Hospital Survey on Patient Safety Culture: 2009 Hospital Survey on Patient Safety Culture: 2009

Comparative Database ReportComparative Database Report Nursing Home Survey on Patient Safety CultureNursing Home Survey on Patient Safety Culture Medical Office Survey on Patient Safety CultureMedical Office Survey on Patient Safety Culture Preventing Hospital-Acquired Venous Preventing Hospital-Acquired Venous

Thromboembolism: A Guide for Effective Quality Thromboembolism: A Guide for Effective Quality ImprovementImprovement

Continued.. Continued..

AHRQ Patient Safety AHRQ Patient Safety ResourcesResources

Transforming Hospitals: Designing for Safety and QualityTransforming Hospitals: Designing for Safety and Quality Advances in Patient Safety: From Research to ImplementationAdvances in Patient Safety: From Research to Implementation Advances in Patient Safety: New Directions and Alternative Advances in Patient Safety: New Directions and Alternative

ApproachesApproaches Patient Safety and Quality: An Evidence-Based Handbook for NursesPatient Safety and Quality: An Evidence-Based Handbook for Nurses Patient Safety Improvement Corps: Tools, Methods, and Techniques Patient Safety Improvement Corps: Tools, Methods, and Techniques

for Improving Patient Safetyfor Improving Patient Safety 10 Patient Safety Tips for Hospitals10 Patient Safety Tips for Hospitals Guide for Developing Patient Safety CouncilsGuide for Developing Patient Safety Councils Your Guide to Preventing and Treating Blood ClotsYour Guide to Preventing and Treating Blood Clots Blood Thinner Pills: Your Guide to Using Them SafelyBlood Thinner Pills: Your Guide to Using Them Safely

http://www.ahrq.gov/qual/errorsix.htmhttp://www.ahrq.gov/qual/errorsix.htm

A world of patient safety information at your fingertips

AHRQ Patient Safety Network (PSNet) and WebM&M

AHRQ Patient Safety Network (PSNet)

• A national “one-stop” portal featuring a collection of resources and content about improving patient safety and preventing medical errors

• Offers weekly updates of patient safety literature, news, tools, conferences, as well as wide variety of information on patient safety

• Diverse users can customize the site around their unique interests by creating a “My PSNet” page

• Web site: http://psnet.ahrq.gov

psnet.ahrq.gov

Search

Patient Safety Primers

AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

• Online journal featuring expert analysis of real medical error cases, perspectives on patient safety, and interviews with experts

• Users submit cases of errors anonymously• Continuing education credit (CME/CEU)

available• Web site: http://webmm.ahrq.gov

webmm.ahrq.gov

Evidence-based Team Training Evidence-based Team Training and Implementation Toolkitand Implementation Toolkit

Set of ready-to-use Set of ready-to-use materials and training materials and training curricula to integrate curricula to integrate teamwork principlesteamwork principles

More than 900 people have More than 900 people have been trained as been trained as TeamSTEPPS trainers as TeamSTEPPS trainers as of July 2009of July 2009

Collaboration between Collaboration between AHRQ and Department of AHRQ and Department of Defense’s military health Defense’s military health systemsystem

http://teamstepps.ahrq.gov/http://teamstepps.ahrq.gov/

TeamSTEPPS Rapid TeamSTEPPS Rapid Response ModuleResponse Module

Rapid Response Systems Rapid Response Systems ―― composed of teams of clinicians who bring critical composed of teams of clinicians who bring critical care expertise to patients requiring immediate treatment while under hospital carecare expertise to patients requiring immediate treatment while under hospital care

Discusses how communication and teamwork strategies taught via Discusses how communication and teamwork strategies taught via TeamSTEPPSTeamSTEPPStools can work for Rapid Response tools can work for Rapid Response SystemsSystems

CD includes:CD includes:– PowerPoint presentationsPowerPoint presentations

– Teaching modulesTeaching modules

– Video vignettesVideo vignettes

AHRQ Publication No. 08(09)-0074-CD. AHRQ Publication No. 08(09)-0074-CD.

AHRQ Suite of Patient Safety AHRQ Suite of Patient Safety Culture Survey ToolsCulture Survey Tools

Suite of tools that measure patient safety culture in Suite of tools that measure patient safety culture in – HospitalsHospitals– Medical officesMedical offices– Nursing homesNursing homes

Tools include survey instruments and report templatesTools include survey instruments and report templates

User's Guide provides information onUser's Guide provides information on– Getting startedGetting started– Selecting a sampleSelecting a sample– Determining data collection methodsDetermining data collection methods– Establishing data collection proceduresEstablishing data collection procedures– Conducting a Web-based surveyConducting a Web-based survey– Preparing and analyzing dataPreparing and analyzing data– Producing reportsProducing reports

Hospital Survey on Patient Hospital Survey on Patient Safety CultureSafety Culture

Helps hospitals and health systems evaluate Helps hospitals and health systems evaluate employee attitudes about patient safety in employee attitudes about patient safety in their facilities or within specific unitstheir facilities or within specific units

Includes survey guide, survey, and feedback Includes survey guide, survey, and feedback report template to customize reportsreport template to customize reports

AHRQ partnership with Premier, Inc., AHRQ partnership with Premier, Inc., Department of Defense, and American Department of Defense, and American Hospital AssociationHospital Association

http://www.ahrq.gov/qual/hospculture/ or e-http://www.ahrq.gov/qual/hospculture/ or e-mail to ahrqpubs@ahrq.govmail to ahrqpubs@ahrq.gov

Hospital Culture Survey Hospital Culture Survey Comparative DatabaseComparative Database

Provides results hospitals can Provides results hospitals can use as benchmarks in use as benchmarks in establishing a patient safety establishing a patient safety culture.culture.

Features a narrative description Features a narrative description of the survey findings, with of the survey findings, with results by hospital and results by hospital and respondent characteristics, as respondent characteristics, as well as trending results for 98 well as trending results for 98 hospitals that submitted data hospitals that submitted data from previous and most recent from previous and most recent safety culture surveys.safety culture surveys.

Appendixes provide data tables Appendixes provide data tables and show trends over time.and show trends over time.

Nursing Home Survey on Nursing Home Survey on Patient Safety CulturePatient Safety Culture

Pilot tested in 40 nursing homesPilot tested in 40 nursing homes Survey materials and technical assistance for survey administration Survey materials and technical assistance for survey administration

are free  are free   Use the survey to:Use the survey to:

– Capture opinions of staff at Capture opinions of staff at all all levels levels

– Assess 12 domains of patient safety cultureAssess 12 domains of patient safety culture

– Benchmark and evaluate patient safety effortsBenchmark and evaluate patient safety efforts

– Track changes in patient safety culture over timeTrack changes in patient safety culture over time

Medical Office Survey On Medical Office Survey On Patient Safety CulturePatient Safety Culture

Pilot tested in 200 officesPilot tested in 200 offices

Free survey materials and technical assistance for survey administrationFree survey materials and technical assistance for survey administration

Designed for providers and staff in medical officesDesigned for providers and staff in medical offices

Includes about 50 items in 12 areas (e.g.Teamwork, Staff Includes about 50 items in 12 areas (e.g.Teamwork, Staff TrainingTraining))

Tracks changes in patient safety and evaluate interventions Tracks changes in patient safety and evaluate interventions over timeover time

Guide Available for Guide Available for Deep Vein ThrombosisDeep Vein Thrombosis

Developed from Partnerships in Developed from Partnerships in Implementing Patient Safety Implementing Patient Safety program toolkitprogram toolkit

Based on quality improvement Based on quality improvement initiatives undertaken at the initiatives undertaken at the University of California, San University of California, San Diego Medical Center and Diego Medical Center and Emory University HospitalsEmory University Hospitals

Assists quality improvement Assists quality improvement practitioners in preventing one practitioners in preventing one of the most important problems of the most important problems facing hospitalized patients - facing hospitalized patients - DVT / PE (VTE)DVT / PE (VTE)

http://www.ahrq.gov/qual/vtguide/http://www.ahrq.gov/qual/vtguide/

Why build a toolkit for VTE Why build a toolkit for VTE Prevention?Prevention?

VTE is a common source of inpatient M&MVTE is a common source of inpatient M&M– Jumbo jet crash / day- Jumbo jet crash / day- >> Breast CA, HIV, MVA combined Breast CA, HIV, MVA combined– May be # 1 preventable source of hospital deathMay be # 1 preventable source of hospital death

Effective and safe methods of prevention existEffective and safe methods of prevention exist– Large “implementation gap” - best practice ≠ current practiceLarge “implementation gap” - best practice ≠ current practice

These methods are grossly underutilizedThese methods are grossly underutilized– Awareness, difficulty implementing, no validated risk assessmentAwareness, difficulty implementing, no validated risk assessment

P4P, public reporting, and core measuresP4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008;133:381S-453S.Cohen, Tapson, Bergmann, et al. ENDORSE study: Lancet 2008; 371: 387–94.

Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS

To Achieve ImprovementTo Achieve Improvement

Real institutional support / prioritizationReal institutional support / prioritization Will to standardizeWill to standardize Physician leadershipPhysician leadership Measurement of process / outcomesMeasurement of process / outcomes Protocol, integrated into order setsProtocol, integrated into order sets EducationEducation Continued refinement / tweaking- PDSAContinued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention

Hierarchy of ReliabilityHierarchy of Reliability

No protocol* (“State of Nature”)No protocol* (“State of Nature”)

Decision support exists but not linked to Decision support exists but not linked to order writing, or prompts within orders order writing, or prompts within orders but no decision supportbut no decision support

Protocol well-integrated Protocol well-integrated

(into orders at point-of-care) (into orders at point-of-care)

Protocol enhancedProtocol enhanced

(by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

The Essential First InterventionThe Essential First Intervention

1) a standardized VTE risk assessment, linked to…1) a standardized VTE risk assessment, linked to…

2) a menu of appropriate prophylaxis options, plus…2) a menu of appropriate prophylaxis options, plus…

3) a list of contraindications to pharmacologic VTE 3) a list of contraindications to pharmacologic VTE prophylaxisprophylaxis

Challenges:Challenges:

Make it easy to use (“automatic”)Make it easy to use (“automatic”)

Make sure it captures almost all patientsMake sure it captures almost all patients

Trade-off between guidance and ease of use / efficiencyTrade-off between guidance and ease of use / efficiency30

VTE Protocol

Low Medium HighLow Medium High

Ambulatory Ambulatory with no other with no other risk factors. risk factors. Same day or Same day or minor surgeryminor surgery

CHFCHF

COPD / PneumoniaCOPD / Pneumonia

Most Medical PatientsMost Medical Patients

Most Gen Surg Most Gen Surg PatientsPatients

Everybody ElseEverybody Else

Elective LE arthroplastyElective LE arthroplasty

Hip/pelvic fxHip/pelvic fx

Acute SCI w/ paresisAcute SCI w/ paresis

Multiple major traumaMultiple major trauma

Abd / pelvic CA surgeryAbd / pelvic CA surgery

Early Early ambulationambulation

UFH 5000 units q 8 h UFH 5000 units q 8 h (5000 units q 12 h if > 75 (5000 units q 12 h if > 75 or weight <50 kg)or weight <50 kg)

LMWH LMWH Enox 40 mg q dayEnox 40 mg q day

Other LMWHOther LMWH

CONSIDER add IPCCONSIDER add IPC

Enox 30 mg q 12 h or Enox 30 mg q 12 h or

Enox 40 q day or Enox 40 q day or

Other LMWH or Other LMWH or

Fondaparinux 2.5 mg q day Fondaparinux 2.5 mg q day or or

Warfarin INR 2-3Warfarin INR 2-3

AND MUST HAVEAND MUST HAVE

IPCIPC 31

IPC needed if contraindication to AC exists

Example from UCSD Keep it Simple – A “3 bucket” model

Map to Reach Level 3Map to Reach Level 3Implementing an Effective VTE Prevention Implementing an Effective VTE Prevention

ProtocolProtocol

Examine existing admit, transfer, periop order Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis.sets with reference to VTE prophylaxis.

Design a protocol-driven DVT prophylaxis order Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment)set (w/ integrated risk assessment)

Vette / Pilot – PDSAVette / Pilot – PDSA Educate / consensus buildingEducate / consensus building Place new standardized DVT order set ‘module’ Place new standardized DVT order set ‘module’

into all pertinent admit, transfer, periop order into all pertinent admit, transfer, periop order sets. sets.

Monitor, tweak - PDSAMonitor, tweak - PDSA

33

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

N = 2,944 mean 82 audits / monthIn press, JHM 2009 In press, Maynard, Morris et al, J Hosp Med

34

UCSD - Decrease in Patients with Preventable HA VTE

0

2

4

6

8

10

12

14

Q 1 '0

5

Q2 '05

Q3 '05

Q4 '05

Q1'06

Q2 '06

Q3 '06

Q4 '06

Q1 '07

Quarter

# o

f P

atie

nts

Medicine

Surgery

Ortho

Other

Total

Hierarchy of ReliabilityHierarchy of Reliability

No protocol* (“State of Nature”)No protocol* (“State of Nature”)

Decision support exists but not linked to Decision support exists but not linked to order writing, or prompts within orders order writing, or prompts within orders but no decision supportbut no decision support

Protocol well-integrated Protocol well-integrated

(into orders at point-of-care) (into orders at point-of-care)

Protocol enhancedProtocol enhanced

(by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

Map to Reach Level 5Map to Reach Level 595+ % prophylaxis95+ % prophylaxis

Use MAR or Automated Reports to Classify all patients Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones:on the Unit as being in one of three zones:

GREEN ZONE - on anticoagulationGREEN ZONE - on anticoagulation

YELLOW ZONE - on mechanical prophylaxis only YELLOW ZONE - on mechanical prophylaxis only

RED ZONE – on no prophylaxisRED ZONE – on no prophylaxis

Act toAct to move patients out of the RED!move patients out of the RED!

Situational Awareness and Situational Awareness and Measure-vention: Getting to Level 5Measure-vention: Getting to Level 5

Identify patients on no anticoagulationIdentify patients on no anticoagulation Empower nurses to place SCDs in Empower nurses to place SCDs in

patients on no prophylaxis as standing patients on no prophylaxis as standing order (if no contraindications)order (if no contraindications)

Contact MD if no anticoagulant in place Contact MD if no anticoagulant in place and no obvious contraindicationand no obvious contraindication– Templated note, text page, etcTemplated note, text page, etc

Need Administration to back up these Need Administration to back up these interventions and make it clear that docs interventions and make it clear that docs can not “shoot the messenger”can not “shoot the messenger”

Collaborative Efforts and Collaborative Efforts and KudosKudos

SHM VTE Prevention Collaborative I - 25 SHM VTE Prevention Collaborative I - 25 sitessites

SHM / VA Pilot Group - 6 sitesSHM / VA Pilot Group - 6 sites SHM / Cerner Pilot Group – 6 sitesSHM / Cerner Pilot Group – 6 sites

AHRQ / QIO (NY, IL, IA) - 60 sitesAHRQ / QIO (NY, IL, IA) - 60 sites IHI Expedition to Prevent VTE – 60 sitesIHI Expedition to Prevent VTE – 60 sites

SHM Team Improvement AwardSHM Team Improvement Award NAPH Safety Net Award NAPH Safety Net Award Venous Disease CoalitionVenous Disease Coalition

AHRQ Simulation GrantsAHRQ Simulation Grants

For research in 2007/2008 For research in 2007/2008 AHRQ sponsored 19 AHRQ sponsored 19 simulation grants for more simulation grants for more than $10 million than $10 million

2-year cooperative 2-year cooperative agreementsagreements

Focused on practitioners and Focused on practitioners and teams in a variety of clinical teams in a variety of clinical settings using a diverse range settings using a diverse range of simulation techniquesof simulation techniques

Intent was to inform Intent was to inform researchers, providers, health researchers, providers, health educators, patients, policy educators, patients, policy makers, payers, and the makers, payers, and the publicpublic

AHRQ’s Grants - A Diverse Range of AHRQ’s Grants - A Diverse Range of Simulated Clinical ApplicationsSimulated Clinical Applications

Central venous catheter insertionCentral venous catheter insertion High volume ambulatory surgical High volume ambulatory surgical

procedures procedures Diagnosis of melanoma Diagnosis of melanoma Obstetric emergency response drills in Obstetric emergency response drills in

rural hospitalsrural hospitals Disclosure of medical errorDisclosure of medical error Improving teamwork & culture of safetyImproving teamwork & culture of safety Patient-tracking systems in the Patient-tracking systems in the

emergency departmentemergency department Acute coronary syndrome management Acute coronary syndrome management

in rural settingin rural setting Medication administrationMedication administration Rapid response emergency team trainingRapid response emergency team training

Management of acute care events by Management of acute care events by graduate physiciansgraduate physicians

Airway management in the pediatric Airway management in the pediatric intensive care unitintensive care unit

Training rapid response teamsTraining rapid response teams Emergent cesarean deliveriesEmergent cesarean deliveries Three-dimensional virtual reality team Three-dimensional virtual reality team

trainingtraining Patient care hand-offsPatient care hand-offs Postanesthesia care unit Postanesthesia care unit

communicationcommunication Pediatric emergency carePediatric emergency care Resuscitation team response in small & Resuscitation team response in small &

rural hospitalsrural hospitals

Evidence Based DesignEvidence Based Design

Build Private RoomsBuild Private Rooms Reduce NoiseReduce Noise Incorporate NatureIncorporate Nature Improve Air QualityImprove Air Quality Encourage Hand Hygiene Encourage Hand Hygiene Improve Wayfinding Improve Wayfinding Reduce Walking DistanceReduce Walking Distance

Transforming Hospitals: Transforming Hospitals: Designing for Safety and QualityDesigning for Safety and Quality

A DVD that demonstrates how A DVD that demonstrates how evidence-based design can evidence-based design can improve the quality and safety improve the quality and safety of hospital services while of hospital services while improving staff satisfaction and improving staff satisfaction and retentionretention

Case studies of three hospitals Case studies of three hospitals illustrateillustrate the benefit of the benefit of incorporating evidence-based incorporating evidence-based design principles into new design principles into new construction or renovation construction or renovation projectsprojects

AHRQ Publication No. 07-0076-DVDAHRQ Publication No. 07-0076-DVD

Advances in Patient Safety: From Advances in Patient Safety: From Research to ImplementationResearch to Implementation

Four-volume set of 140 peer-reviewed Four-volume set of 140 peer-reviewed articles representing an overview of articles representing an overview of patient safety studiespatient safety studies

AHRQ Publication No. 05-0021-CDAHRQ Publication No. 05-0021-CD

Describes new patient safety findings, Describes new patient safety findings, investigative approaches, process investigative approaches, process analyses, lessons learned, and analyses, lessons learned, and practical tools to prevent harming practical tools to prevent harming patients patients

4-volume set or 1 CD of 115 articles on 4-volume set or 1 CD of 115 articles on reporting systems, risk assessment, reporting systems, risk assessment, safety culture, medical simulation, safety culture, medical simulation, patient safety tools and practices, patient safety tools and practices, health information technology, health information technology, medication safety, and moremedication safety, and more

Advances in Patient Safety: New Advances in Patient Safety: New

Directions and Alternative ApproachesDirections and Alternative Approaches

AHRQ Publication No. 08-0034 (print copy) AHRQ Publication No. 08-0034 (print copy) or 08-0034-CD (Searchable CD-ROM) or 08-0034-CD (Searchable CD-ROM)

Handbook for NursesHandbook for Nurses

Comprehensive, 1400-page Comprehensive, 1400-page handbook for nurses on handbook for nurses on patient safety and quality.patient safety and quality.

Experts in the field reviewed Experts in the field reviewed the literature, and their the literature, and their contributions are grouped contributions are grouped into sections that address :into sections that address :

– Patient safety and qualityPatient safety and quality– Evidence-based practiceEvidence-based practice– Patient-centered care Patient-centered care – Working conditions—work Working conditions—work

environment environment – Critical opportunities for Critical opportunities for

patient safety and quality patient safety and quality – Tools Tools

AHRQ Publication No. 08-0043 (print copy) or 08-0043-CD (CD-ROM)AHRQ Publication No. 08-0043 (print copy) or 08-0043-CD (CD-ROM)

Patient Safety Improvement CorpsPatient Safety Improvement Corps

DVD features a self-paced, DVD features a self-paced, modular approach to training modular approach to training individuals involved in patient individuals involved in patient safety activities at the safety activities at the institutional level.institutional level.

Modules address:Modules address:– Investigation of medical Investigation of medical

errors and their root causes.errors and their root causes.– Identification, Identification,

implementation, and implementation, and evaluation of system-level evaluation of system-level interventions to address interventions to address patient safety concerns.patient safety concerns.

– Steps necessary to promote Steps necessary to promote a culture of safety within a a culture of safety within a hospital or other health care hospital or other health care facility. facility.

AHRQ Publication No. 07-0035-DVDAHRQ Publication No. 07-0035-DVD

10 Patient Safety Tips for 10 Patient Safety Tips for HospitalsHospitals

Evidence-based tips help hospitals promote Evidence-based tips help hospitals promote patient safetypatient safety

Go to:Go to: http://www.ahrq.gov/qual/10tips.pdf http://www.ahrq.gov/qual/10tips.pdf

Guide for Developing Guide for Developing Patient Safety CouncilsPatient Safety Councils

Provides information and Provides information and guidance to empower guidance to empower individuals and organizations to individuals and organizations to develop a community-based develop a community-based advisory counciladvisory council

Councils involve patients, Councils involve patients, consumers, and a variety of consumers, and a variety of practitioners and professionals practitioners and professionals from health care and from health care and community organizationscommunity organizations

Councils drive change for Councils drive change for patient safety through patient safety through education, collaboration, and education, collaboration, and consumer engagement consumer engagement

http://www.ahrq.gov/qual/advisorycouncil/http://www.ahrq.gov/qual/advisorycouncil/

Blood Clot PreventionBlood Clot Prevention

Deep vein thrombosis is a potentially Deep vein thrombosis is a potentially deadly medical problem that affects deadly medical problem that affects at least 350,000 and possibly as at least 350,000 and possibly as many as 600,000 Americans each many as 600,000 Americans each yearyear

24-page easy-to-read booklet in 24-page easy-to-read booklet in English and Spanish that helps both English and Spanish that helps both patients and their families:patients and their families:– Identify the causes and symptoms Identify the causes and symptoms

of dangerous blood clots.of dangerous blood clots.– Learn tips on how to prevent them. Learn tips on how to prevent them. – Know what to expect during Know what to expect during

treatment. treatment. Created by experts funded through Created by experts funded through

AHRQ's Partnerships in AHRQ's Partnerships in Implementing Patient Safety grant Implementing Patient Safety grant programprogram

http://www.ahrq.gov/consumer/bloodclots.htmhttp://www.ahrq.gov/consumer/bloodclots.htm

Blood Thinner Pills: Your Blood Thinner Pills: Your Guide to Using Them SafelyGuide to Using Them Safely

Consumer publication and DVD Consumer publication and DVD explain what to expect and watch explain what to expect and watch out for while taking blood thinner out for while taking blood thinner pillspills

Based on research originally Based on research originally conducted by one of AHRQ’s conducted by one of AHRQ’s Partnership for Implementing Patient Partnership for Implementing Patient Safety grant projectsSafety grant projects

Educates patients about:Educates patients about:– Medication therapy and potential side Medication therapy and potential side

effects effects

– How to communicate effectively with How to communicate effectively with their health care providerstheir health care providers

– Tips for lifestyle modificationsTips for lifestyle modifications

http://www.ahrq.gov/consumer/btpills.htmhttp://www.ahrq.gov/consumer/btpills.htm

How to Order?How to Order?

Ordering information for AHRQ Ordering information for AHRQ Publications & Products available atPublications & Products available at

http://www.ahrq.gov/news/pubsix.htmhttp://www.ahrq.gov/news/pubsix.htm

Call the AHRQ Publication Clearinghouse at 1-800-358-9295

Send an email to AHRQPubs@ahrq.hhs.gov