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Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System

Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System

Donna O. Farley
M. Susan Ridgely
Peter Mendel
Stephanie S. Teleki
Cheryl L. Damberg
Rebecca Shaw
Michael D. Greenberg
Amelia M. Haviland
Peter Hussey
Jacob W. Dembosky
Hao Yu
Julie A. Brown
Chau Pham
J. Scott Ashwood
Copyright Date: 2009
Edition: 1
Published by: RAND Corporation
Pages: 230
Stable URL: http://www.jstor.org/stable/10.7249/tr725ahrq
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  • Book Info
    Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System
    Book Description:

    Presents the results of a two-year study that analyzes how patient safety practices are being adopted by U.S. health care providers, examines hospital experiences with a patient safety culture survey, and assesses patient safety outcomes trends. In case studies of four U.S. communities, researchers collected information on the dynamics of local patient safety activities and on adoption of safe practices by hospitals.

    eISBN: 978-0-8330-4902-5
    Subjects: Health Sciences, Sociology
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Table of Contents

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  1. Front Matter (pp. i-ii)
  2. PREFACE (pp. iii-iv)
  3. Table of Contents (pp. v-vi)
  4. FIGURES (pp. vii-viii)
  5. TABLES (pp. ix-x)
  6. EXECUTIVE SUMMARY (pp. xi-xxvi)
  7. ACKNOWLEDGMENTS (pp. xxvii-xxviii)
  8. CHAPTER 1. INTRODUCTION AND BACKGROUND (pp. 1-8)

    In early 2000, the Institute of Medicine (IOM) published the report entitledTo Err Is Human: Building a Safer Health System, calling for leadership from the U.S. Department of Health and Human Services (DHHS) in reducing medical errors, and identifying the Agency for Healthcare Research and Quality (AHRQ) as the lead agency for patient safety research and practice improvement (IOM, 2000). Soon thereafter, the U.S. Congress funded AHRQ, in the Department of Health and Human Services, to establish a national patient safety initiative. This initiative represents one of numerous, important patient safety efforts being undertaken by organizations across the country...

  9. CHAPTER 2. UPTAKE OF PATIENT SAFETY PRACTICES IN FOUR U. S. COMMUNITIES (pp. 9-36)

    1. To trace the evolution of patient safety efforts in four U.S. communities that are typical of local health care markets in various regions of the United States. The unit of analysis is the community. The focus was to document patient safety initiatives and trends over time across three specific sectors within each community: hospitals, ambulatory settings, and long-term care facilities.

    2. To understand, in particular, how hospitals in those communities made decisions about adoption of safe practices and how they implemented them within their institutions. The unit of analysis was the individual hospital. The focus was to understand how hospitals are...

  10. CHAPTER 3. USE OF THE HOSPITAL SURVEY ON PATIENT SAFETY CULTURE (pp. 37-52)

    One of the major tools that AHRQ developed to help health care providers improve their patient safety culture and practices is the Survey on Patient Safety Culture (SOPS). The first survey developed was the Hospital Survey on Patient Safety Culture (HSOPS). We gathered and assessed information on hospitals’ experiences to achieve the following aims:

    1. To develop information on hospitals’ motivation and experiences in using the HSOPS

    2. To understand the extent to which the HSOPS has contributed to hospitals’ patient safety efforts

    3. To provide feedback to AHRQ on how it might modify the survey questionnaire or technical support to enhance the...

  11. CHAPTER 4. NATIONAL SURVEY ON ADOPTION OF NQF SAFE PRACTICES (pp. 53-69)

    An important part of AHRQ’s patient safety initiative is monitoring and assessing the extent to which safe practices are being adopted in the national health care community. Yet the greatest challenge in developing data on the adoption of patient safety practices in the U.S. health care system has been the inability to measure effectively the extent to which each practice actually is being used by providers. Therefore, we saw development of a data-collection instrument as the first important step to take in this area. The specific aims of this surveydevelopment work are as follows:

    1. To support AHRQ’s efforts to monitor...

  12. CHAPTER 5. TRENDS FOR PATIENT SAFETY OUTCOMES (pp. 69-92)

    1. Continue much of the outcome trend analysis performed during the third and fourth years of the patient safety evaluation, adding data for the years 2004 and 2005 to the trends. Any effects of the patient safety initiative on outcomes might begin to be seen in these two years.

    2. Perform additional geographic analyses to identify possible patterns of outcome differences or changes in relation to possible patterns of diffusion of safe practices in the health care system (e.g., in multihospital systems).

    Our work in evaluating patient safety outcomes followed two tracks during the two-year assessment focusing on practice diffusion. First, we...

  13. CHAPTER 6. SUGGESTED APPROACH FOR MONITORING EFFECTS OF THE PATIENT SAFETY INITIATIVE (pp. 93-102)

    1. To provide suggestions to AHRQ regarding the structure and processes for a program of ongoing monitoring of patient safety outcomes, performed either by itself or through an external contractor, after the work of the Patient Safety Evaluation Center is completed.

    Over the course of our work on the patient safety evaluation, we have developed a framework for examining the effects of nationwide patient safety activities, including those of the AHRQ patient safety initiative. We also have identified some measures to assess these effects, and we have performed analyses for these measures. This work has been our productevaluation component of the...

  14. APPENDIX A. BOUNDARY SPANNERS INTERVIEWED IN THE COMMUNITY STUDY (pp. 103-104)
  15. APPENDIX B. CASE STUDIES FROM THE COMMUNITY STUDY (pp. 105-134)
  16. APPENDIX C. SUMMARY OF RESULTS FROM ROUNDTABLE DISCUSSIONS ON NQF SAFE PRACTICES (pp. 135-140)
  17. APPENDIX D. NQF SAFE PRACTICES NOT INCLUDED IN SURVEY (pp. 141-142)
  18. APPENDIX E. FINAL VERSION OF THE SURVEY (pp. 143-172)
  19. APPENDIX F. RATIONALE FOR DESIGN OF THE SURVEY ITEMS (pp. 173-196)
  20. REFERENCES (pp. 197-202)