Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture, TeamSTEPPS®

The Kaiser Permanente (KP) School of Anesthesia in Pasadena, Calif., uses AHRQ’s Surveys on Patient Safety Culture (SOPS®) to improve ambulatory care and expand doctoral students’ education. The school has used the SOPS Hospital Survey in the past and recently conducted an analysis of nationwide data from the SOPS Ambulatory Surgery Center Survey. Using the findings, school officials are working to improve patient safety and training for certified registered nurse anesthetists (CRNAs) using TeamSTEPPS.

��Ƶsurveys are available for hospitals, medical offices, nursing homes, community pharmacies and ambulatory surgery centers (ASCs). The ASC survey is designed to get feedback from the staff about the culture of patient safety where they work.

“Each year, KP School of Anesthesiology students must complete rigorous projects clinically relevant to nurse anesthesiology,” explained Mark Gabot, D.N.P., CRNA, faculty advisor for the project. “I worked with the hospital SOPS survey a couple of years ago. This time, I wanted to do something on a larger scale. We reached out to ��Ƶand were able to get access to the nationwide ASC data for 2021 through 2023. Both certified registered nurse anesthetists (CRNAs) and physician anesthesiologists had completed the surveys,” he said.

The project helped identify strengths and areas for improvement, as well as create best-practice recommendations for patient safety from an anesthesia-informed perspective. After reviewing the data, the team recommended regular use of ASC SOPS and TeamSTEPPS, establishment of a “just culture” for anesthesia practitioners and implementation of a patient safety reporting system.

In response to the project results, the KP School of Anesthesia is improving its TeamSTEPPS training program. “Every year, we conduct TeamSTEPPS training for our students to promote that just culture,” Dr. Gabot said. “Thanks to this project, we’re actually reformatting our TeamSTEPPS approach and education to reflect what the team found in the secondary analysis study.”

New ��ƵToolkit Tackles MRSA and Surgical Site Infections

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most invasive and deadly multidrug-resistant organisms. Preventing MRSA and surgical site infections is a complex patient safety issue that requires a multifaceted effort. AHRQ’s new MRSA Prevention Toolkit: Targeting SSI provides extensive resources, including PowerPoint presentations, facilitator guides, one-page summary documents and staff and patient training materials to help your facility get started or supplement your existing MRSA reduction efforts for cardiac, hip and knee replacement and spinal fusion surgeries.

Electronic Clinical Surveillance Identifies Sepsis Antibiotic Overtreatment

Researchers for an AHRQ-funded study in Clinical Infectious Diseases developed a new sepsis overtreatment surveillance metric and subsequently established the validity and usefulness of electronic health record data–derived criteria. The measure identified a 22.5 percent overtreatment in 113,764 adult patients admitted to the emergency department with suspected sepsis who received intravenous antibiotics within three hours of admission without a blood culture sepsis test. Further, the instrument found that 7.6 percent of patients were overtreated and received antibiotics within one hour after admission. The results showed that the average number of antibiotic days, average length of stay and hospitality mortality rate were all higher for patients who received antibiotic overtreatment, and also showed a higher incidence of Clostridioides difficile infection within six months of discharge. Access the .

Explore the Latest ��ƵData on Healthcare Spending on Americans With High Expenses

In 2022, 21.7 percent of healthcare spending was done by the highest 1 percent of spenders. Each year, ��Ƶgathers the most up-to-date information on high spenders and makes it available through our data visualization series. Now updated with 2022 statistics, this interactive tool makes it easy to track the most common conditions, demographics, payers and service types associated with high spending. Explore the latest data and check out the highlights in our .

Data Submission Opens for ��ƵCAHPS Health Plan Survey: June 2–27

Voluntary data submission for AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey Database is open from June 2 to June 27. Organizations that administered the CAHPS 5.1 or 5.1H Health Plan Survey between June 29, 2024, and June 27, 2025, are eligible to submit data. The database is accepting submissions for the Adult Medicaid survey, the Child Medicaid or Children’s Health Insurance Program (CHIP) survey without the Children with Chronic Conditions Item Set and the Child Medicaid or CHIP survey with the Item Set. Participating organizations will receive a private feedback report comparing their results with aggregated data from other participants and access to database products that support quality improvement and research. Learn more about submission requirements and data specifications at .

Recording of Maternal Health Webinar Now Available

AHRQ’s National Center for Excellence in Primary Care Research Webinar, “The Role of Primary Care in Maternal Health: Factors that Impact Perinatal Care Experience and Outcomes,” held March 6, explored key factors affecting perinatal care. Speakers from Oregon Health & Science University, University of Michigan and Harvard School of Public Health emphasized the need for respectful maternal care. All speakers agreed that better care coordination and communication are critical to improving maternal and infant health outcomes. The panelists answered audience questions on strategies for implementing respectful maternity care training, integrating primary care follow-up into postpartum care models and evaluating the health and economic impacts of Medicaid extension on postpartum outcomes. Access the recording and presenter materials for this event.

Register for Upcoming Webinars

May 7, 1–2:30 p.m. ET: . ��Ƶis conducting a gap analysis to identify opportunities to improve and expand Patient Safety Indicators, including into new care settings and populations. This webinar will share the interim findings of the analysis, featuring initial reactions from Sue Sheridan, M.I.M., M.B.A., and Peter Pronovost, M.D., Ph.D. Feedback is welcome from a broad range of stakeholders.
May 8, 11–11:30 a.m. ET, and May 14, 2–2:30 p.m. ET: . Learn how participants in the program will receive expert support to prevent infections and promote safety culture.
May 13, noon–1 p.m. ET: Implementing CMS’ Patient Safety Structural Measure (PSSM). This webinar from the National Action Alliance for Patient and Workforce Safety will include leaders on the front line of PSSM implementation and delve into tools and resources that support implementation of the five domains of the PSSM: Leadership Commitment, Strategic Planning and Organizational Policy, Culture of Safety and Learning Health System, Accountability and Transparency, and Patient and Family Engagement.

��Ƶin the Professional Literature

Changes in blood pressure, medication adherence, and cardiovascular-related health care use associated with the 2018 angiotensin receptor blocker recalls and drug shortages among patients with hypertension. Callaway Kim K, Roberts ET, Donohue JM, et al. J Manag Care Spec Pharm 2025 May;31(5):461-71. Access the on PubMed®.

Designing health care provider-centered emergency department interventions: participatory design study. Seo W, Li J, Zhang Z, et al. JMIR Form Res 2025 Apr 21;9:e68891. Access the on PubMed®.

Between-visit asthma symptom monitoring with a scalable digital intervention: a randomized clinical trial. Rudin RS, Plombon S, Sulca Flores J, et al. JAMA Netw Open 2025 Apr 1;8(4):e256219. Access the on PubMed®.

Challenges of managing pediatric polypharmacy in a pediatric complex care program: a qualitative pilot study. Reedy J, Thompson T, Begum A, et al. J Am Pharm Assoc 2025 Mar 22. [Epub ahead of print.] Access the on PubMed®.

NICU parent and staff advocacy to address parental mental health. Klawetter S, Gievers L, McEvoy CT, et al. Clin Pediatr 2025 Feb;64(2):247-56. Epub 2024 Jun 10. Access the on PubMed®.

Methodology of a social network survey in primary care practices with medical home attributes. Dixon J, Turi E, Pollifrone M, et al. J Ambul Care Manage 2025 Apr-Jun;48(2):84-94. Epub 2025 Feb 24. Access the on PubMed®.

User-centered design of a preference-driven patient activation tool for optimizing depression treatment in integrated primary care settings (The Transform DepCare Study). Dauber-Decker KL, Serafini MA, Monane R, et al. J Gen Intern Med 2025 Feb;40(2):556-68. Epub 2024 Jun 4. Access the on PubMed®.

Development of an evidence- and consensus-based Digital Healthcare Equity Framework. Hatef E, Hudson Scholle S, Buckley B, et al. JAMIA Open 2024 Dec;7(4):ooae136. Epub 2024 Nov 15. Access the on PubMed®.

SHARE: