AHRQ Patient Safety Network

The Collection > Quality Improvement Strategies

PATIENT SAFETY PRIMERS
Detection of Safety Hazards

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Safety Target

•Device-related Complications (72)

•Diagnostic Errors (101)

•Identification Errors (41)

•Discontinuities, Gaps, and Hand-Off Problems (128)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (380)

•Medical Complications (207)

•Nonsurgical Procedural Complications (43)

•Surgical Complications (138)

•Transfusion Complications (6)

•Psychological and Social Complications (24)

Origin/Sponsor

•Africa (1)

•Asia (20)

•Australia and New Zealand (26)

•Central and South America (2)

•Europe (141)

•North America (1114)

Resource Types

•Clinical Guideline (6)

•Journal Article (859)

•Legislation/Regulation (31)

•Meeting/Conference (13)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (151)

•Press Release/Announcement (8)

•Special or Theme Issue (38)

•Tools/Toolkit (28)

•Web Resource (58)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (211)

•Active Errors (219)

•Latent Errors (79)

•Near Miss (16)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (202)

•Benchmarking (78)

•Continuous Quality Improvement (24)

•Critical Pathways (48)

•Practice Guidelines (202)

•Reminders (39)

•Patient Self-Management (128)

•Six Sigma (9)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (933)

•Health Care Executives and Administrators (1137)

•Non-Health Care Professionals (432)

•Patients (113)

Setting of Care

•Hospitals (771)

•Psychiatric Facilities (7)

•Residential Facilities (20)

•Ambulatory Care (140)

•Outpatient Surgery (22)

•Patient Transport (8)

1 - 20 of 1348

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REVIEW

Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature.

Schwappach DLB, Wernli M. Eur J Cancer Care (Engl). 2009;19:285-292.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

STUDY

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

Health literacy and quality: focus on chronic illness care and patient safety.

Rothman RL, Yin HS, Mulvaney S, Co JPT, Homer C, Lannon C. Pediatrics. 2009;124(suppl 3):S315-S326.

COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

STUDY

Medication reconciliation in ambulatory care: attempts at improvement.

Nassaralla CL, Naessens JM, Hunt VL, et al. Qual Saf Health Care. 2009;18:402-407.

COMMENTARY

The Role of Health Literacy in Patient Safety

Wolf MS, Cooper Bailey S. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

COMMENTARY

Sick and Pregnant

El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

STUDY

Communication discrepancies between physicians and hospitalized patients.

Olson DP, Windish DM. Arch Intern Med. 2010;170:1302-1307.

STUDY

Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital.

Sacks GS, Rough S, Kudsk KA. Pharmacotherapy. 2009;29:966-974.

STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

COMMENTARY

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.

STUDY

Chemotherapy patients' perceptions of drug administration safety.

Schwappach DLB, Wernli M. J Clin Oncol. 2010;28:2896-2901.

STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

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