AHRQ News Now: Special Issue on Patient Safety Awareness Week

AHRQ News Now

March 12, 2019, Issue #655

AHRQ Stats: Improvement in Patient Safety Measures

From 2000 to 2016, more than two-thirds of patient safety measures were improving overall. Measures showing the most improvement included reduced adverse events among hospital patients receiving knee and hip joint replacement. (Source: National Healthcare Quality and Disparities Report Chartbook on Patient Safety, October 2018.

Today's Headlines:

AHRQ Joins Partners in Patient Safety Awareness Week Activities


For Patient Safety Awareness Week 2019, AHRQ is working with the Institute for Healthcare Improvement (IHI) and other partners to raise awareness about the importance of improving safety beyond the hospital in ambulatory settings. As the nation’s patient safety agency, AHRQ is supporting this event with a wide variety of activities. Plan to join us throughout the week:

  • Register for the free webcast, “Advancing Patient Safety Beyond the Hospital,” on Wednesday, March 13, from 2 to 3 p.m. ET. Jeff Brady, M.D., director of AHRQ’s Center for Quality Improvement and Patient Safety, and Lisa Schilling, R.N., vice president for quality, safety and clinical effectiveness at Stanford Health Care, will discuss the state of safety in ambulatory settings. Tejal Gandhi, M.D., IHI’s chief clinical and safety officer, will moderate the discussion.
  • Read Dr. Brady’s Patient Safety Awareness Week blog post and watch his video message. The post outlines the challenges and opportunities in promoting safer ambulatory care and highlights AHRQ’s involvement in the ongoing work of the National Steering Committee for Patient Safety.
  • Join the Twitter chat, “Improving Diagnosis: A Foundation for Safe Care” on Thursday, March 14, from noon to 1 p.m. ET. Use #PSAW19 to participate in the conversation. The chat is co-hosted by IHI and our partner the Society to Improve Diagnosis in Medicine.
  • Follow us on @AHRQNews, Facebook and LinkedIn. We will be highlighting select AHRQ resources that can help clinicians, patients and families make care safer in ambulatory settings. 

New AHRQ Question Builder App Helps Patients Maximize Time With Clinicians

AHRQ today released a new mobile app to help patients be more engaged in their own healthcare and to help make office visits more efficient. The Question Builder app, available free of charge on iTunes and Google Play, helps patients prepare and organize questions and other helpful information ahead of time, and puts that information at their fingertips as part of an email or calendar appointment that allows for note-taking during medical visits. The Question Builder app has a host of other features. For instance, it integrates with a phone’s camera so that users can snap a photo of useful visual information such as an insurance card, a pill bottle or even a skin rash. Find out more about the new app and read AHRQ’s press release

Nurse Involvement Can Boost Antibiotic Stewardship Efforts

Including bedside nurses in antibiotic stewardship activities has been identified by professional nursing groups and the CDC as an important—but missing—element in the success of these programs. To help fill this void, a new AHRQ-funded study published in the journal Infection Control and Hospital Epidemiology identifies several areas where bedside nurses could play an enhanced role in improving antibiotic prescribing practices. Nurses’ expertise can be used to: ensure appropriate testing for Clostridiodes difficile (C. diff) infection through accurate documentation and medication reviews; assess relevant indications before obtaining urine culture specimens to prevent the use of unnecessary antibiotics; ensure optimal antibiotic administration by helping patients transition from intravenous to oral therapies; obtain and document accurate patient histories of penicillin allergies; and use a team-based review to ensure that antibiotic therapies are not unnecessarily prolonged. The authors also identified ways to integrate nurses into an organization’s stewardship program, including on-the-job learning about antibiotics, potential drug interactions and adverse drug events. Effective communication and teamwork can also enhance nurses’ involvement in antibiotic stewardship activities, using tools such as AHRQ’s Safety Program for Improving Antibiotic Use. Access the abstract.

AHRQ Patient Safety Learning Labs Help Identify Barriers to Making Care Safer

A recent article by AHRQ researchers in the Journal of Patient Safety describes the challenges and obstacles confronted by AHRQ-funded Patient Safety Learning Laboratories (PSLLs). The 22 PSLLs are multidisciplinary teams that use design thinking and systems engineering principles to understand safety challenges and improve healthcare delivery systems. Each PSLL employs a five-phase methodology—problem analysis, design, development, implementation and evaluation—as the foundation for its four-year project. Though most of the PSLL work is in progress, the article’s authors suggested the impact of the initiative can be described in three ways: sharing results and lessons learned with the scientific community; enhancing care delivery to some degree at the system or unit level; and spurring the beginning of culture change for institutions to address problems. Access the abstract, and learn more about new PSLL projects aimed at supporting AHRQ’s growing emphasis on promoting diagnostic safety.

Highlights From AHRQ’s Patient Safety Network

AHRQ’s Patient Safety Network (PSNet) highlights journal articles, books and tools related to patient safety. Articles featured this week include:

Review additional new publications in PSNet’s current issue or access recent cases and commentaries in AHRQ’s WebM&M (Morbidity and Mortality Rounds on the Web).

New Video Highlights How AHRQ Surveys on Patient Safety Culture Can Be Used in Different Care Settings


A new video, “Five Reasons to Choose One of the Surveys on Patient Safety Culture,” highlights how AHRQ’s surveys can be used in different settings of care. The AHRQ culture surveys enable healthcare organizations to assess how their clinicians and staff perceive various aspects of patient safety culture in hospitals, nursing homes, medical offices, community pharmacies and ambulatory surgery centers. Various AHRQ products include the surveys, instructions on administering the surveys, supplemental items, a data entry and analysis tool and database reports. Learn more.

Case Studies Show Impact of AHRQ’s Patient Safety Resources, Tools

Since AHRQ’s inception, the agency has focused on patient safety. A glimpse into some successes in this area is available online in our Impact Case Studies. The 15 years’ worth of case studies includes 145 about patient safety, which show examples of how AHRQ resources are being used every day to improve outcomes and care. For example, Tri-City Medical Center, a 388-bed hospital in Oceanside, California, reduced central line-associated bloodstream infections by 33 percent and improved the on-time delivery of insulin to patients by 55 percent after changing patient care practices based on strategies from AHRQ’s Comprehensive Unit-based Safety Program (CUSP). Access AHRQ’s full range of Impact Case Studies to learn how AHRQ’s investments have been making a difference nationwide.  

AHRQ in the Professional Literature

Cutting-edge efforts in surgical patient safety. Varghese TK, Jr., Ghaferi AA. JAMA Surg. 2017 Aug 1;152(8):719-20. Access the abstract on PubMed®.

Measuring patient safety culture in pediatric long-term care. Hessels AJ, Agarwal M, Saiman L, et al. J Pediatr Rehabil Med. 2017 May 17;10(2):81-7. Access the abstract on PubMed®.

The hospital: still the doctors' workplace(s) - a cautionary note for approaches to safety and value improvement. McMahon LF, Jr., Howell JD. Health Serv Res. 2018 Apr;53(2):601-7. Epub 2017 Oct 9. Access the abstract on PubMed®.

Communicating findings of delayed diagnostic evaluation to primary care providers. Meyer AN, Murphy DR, Singh H. J Am Board Fam Med. 2016 Jul-Aug;29(4):469-73. Access the abstract on PubMed®.

Implications of electronic health record downtime: an analysis of patient safety event reports. Larsen E, Fong A, Wernz C, et al. J Am Med Inform Assoc. 2018 Feb 1;25(2):187-91. Access the abstract on PubMed®.

Design of a user-centered voluntary reporting system for patient safety events. Kang H, Gong Y. Stud Health Technol Inform. 2017;245:733-7. Access the abstract on PubMed®.

Towards a usability and error "safety net": a multi-phased multi-method approach to ensuring system usability and safety. Kushniruk A, Senathirajah Y, Borycki E. Stud Health Technol Inform. 2017;245:763-7. Access the abstract on PubMed®.

Improving best possible medication history with vulnerable patients at an urban safety net academic hospital using pharmacy technicians. Sadasivaiah S, Smith DE, Goldman S, et al. BMJ Open Qual. 2017 Oct 21;6(2):e000102. eCollection 2017. Access the abstract on PubMed®.

Contact Information

For comments or questions about AHRQ News Now, contact Bruce Seeman, (301) 427-1998 or Bruce.Seeman@ahrq.hhs.gov.