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Patient Safety, Quality Improvement, & Complex Systems

Provides resources for students, clinicians, researchers, & administrators on patient safety, quality improvement, & complex healthcare systems.

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News

 

AHRQ logo

In this blog post,  Jeff Brady, M.D., M. P. H., Director of AHRQ’s Center for Patient Safety and Quality Improvement, outlines the challenges and opportunities in promoting safer care in ambulatory care settings. 

Michigan Medicine/Ann Arbor VA Resources

Michigan Medicine has been a national leader in patient safety for years.  Below are some links to important patient safety resources from Michigan Medicine and the Ann Arbor VA Hospital.

Resource Focus

Studying complexity in health services research: desperately seeking an overdue paradigm shift. 

Trisha Greenhalgh and Chrysanthi Papoutsi, BMC Medicine 2018; 16:95

Abstract

Complexity is much talked about but sub-optimally studied in health services research. Although the significance of the complex system as an analytic lens is increasingly recognised, many researchers are still using methods that assume a closed system in which predictive studies in general, and controlled experiments in particular, are possible and preferred. We argue that in open systems characterised by dynamically changing inter-relationships and tensions, conventional research designs predicated on linearity and predictability must be augmented by the study of how we can best deal with uncertainty, unpredictability and emergent causality. . . . Each of the initial five papers in this collection illustrates, in different ways, the value of theoretically grounded, methodologically pluralistic, flexible and adaptive study designs. We propose an agenda for future research and invite researchers to contribute to this on-going series.

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CANDOR

Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This AHRQ toolkit, based on the CANDOR process, is intended to assist hospitals in implementing communication and optimal resolution programs.