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Health Updates on the Web
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The Patient Safety Group has compiled the latest in health, quality, and safety, news and reports.
AHRQ Innovations Exchange
Guide to Long Term Care for Veterans
Apr-09-2014
This guide provides tools and resources for veterans, caregivers and families, and U.S. Department of Veterans Affairs providers and staff to explore long-term care options.
Improving Outcomes for an Aging Population: Alzheimer's Treatment in Long-Term Care
Apr-09-2014
This toolkit provides strategies and templates to help long-term care facilities and their clinicians implement projects to enhance the quality of care for elderly residents with Alzheimer’s disease.
Long-Term Care Facilities Cede Control of Immunization Policies to Regional Pharmacy, Significantly Increasing Influenza Vaccination Rates Among Workers
Apr-09-2014
A group of 14 long-term care facilities cede control of immunization policies to a regional pharmacy, leading to a significant increase in influenza vaccination rates among facility workers.
Medical Home for Patients With Disabilities and Chronic Conditions Improves Access and Self-Management Skills, Leading to More Healthy Days, Fewer Hospitalizations
Apr-09-2014
A primary care medical home for patients with disabilities and complex, chronic medical conditions emphasizes patient engagement and care coordination among medical specialties and social service providers, leading to enhanced access to care, better self-management skills, more days of good health, fewer hospitalizations, and lower costs.
On-Time Quality Improvement Manual for Long-Term Care Facilities
Apr-09-2014
The On-Time Quality Improvement program is a practical approach to quality improvement (QI) in long-term care, embedding QI strategies and best practices into health information technology. This manual is an introduction to the On-Time QI approach.
State Uses Financial Incentives To Fund Nursing Home–Initiated Quality Improvement Projects Through Competitive Bidding Process, Leading to Better Care
Apr-09-2014
The State of Minnesota uses financial rewards and penalties to fund nursing home–initiated quality improvement projects through a competitive bidding process, leading to improvements in the quality of care.
States Turn to Managed Care To Constrain Medicaid Long-Term Care Costs
Apr-09-2014

Transitioning Newborns From NICU to Home: A Resource Toolkit
Apr-09-2014
This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit.

AHRQ WEBMM
SPOTLIGHT CASE AND COMMENTARY: Multifactorial Medication Mishap
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
CASE AND COMMENTARY: Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
A woman with coronary artery disease, diabetes, and hypertension was admitted for a myocardial infarction. Following percutaneous coronary intervention, the patient had several runs of non-sustained ventricular tachycardia (NSVT) and later experienced a cardiac arrest secondary to sustained VT.
CASE AND COMMENTARY: An Easily Forgotten Tube
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
In Conversation with...Enrico Coiera, MB, BS, PhD
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
This piece describes the research around the effect of interruptions and distractions on health care safety and advocates for promoting and teaching mindfulness to address risks.

BLOG
Hospitalist Potpourri
Apr-14-2014
I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it. As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the […]
Patient Safety’s First Scandal: The Sad Case of Chuck Denham, CareFusion, and the NQF
Jan-30-2014
In retrospect – always in retrospect – it should have been obvious that, when it came to Dr. Charles Denham, something was not quite right. In a remarkable number of cases of medical errors, it’s clear – again, in retrospect – that there were signs that something was amiss, but they were ignored. The reasons […]
Global Health Hospitalists: Strange but Noble Bedfellows
Dec-19-2013
As my Division of Hospital Medicine has grown – now to about 60 faculty – I spend part of my time figuring out what direction we should go in. At times, the path is obvious. It didn’t take Wayne Gretsky to recognize that we needed expertise in healthcare IT a decade ago, or in cost […]
Lights, Camera, Action… In Healthcare
Oct-19-2013
About eight years ago I was desperate to improve my golf game. I just couldn’t straighten out my drives or hit my irons crisply. (Yes, I’m fully aware that this is a First World problem). I decided to try golf camp in Palm Springs for a few days. My sensei, a crusty ex-touring pro named […]



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AHRQ 411
Healthcare 411 podcasts from AHRQ
Radio Series - Autism Consumer Guide
Apr-23-2013 - Duration: 01:00 (mm:ss)
Radio Series - Chronic Hepatitis C
Apr-17-2013 - Duration: 01:00 (mm:ss)
Radio Series - Monitoring Blood Sugar
Apr-10-2013 - Duration: 01:00 (mm:ss)
Radio Series - Medicines for Treating Depression
Apr-03-2013 - Duration: 01:00 (mm:ss)