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 (58)

•Diagnostic Errors (50)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (96)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (297)

•Medical Complications (186)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (103)

•Transfusion Complications (11)

•Psychological and Social Complications (23)

Origin/Sponsor

•Africa (1)

•Asia (11)

•Australia and New Zealand (13)

•Central and South America (1)

•Europe (107)

•North America (1029)

Resource Types

•Clinical Guideline (2)

•Journal Article (704)

•Legislation/Regulation (23)

•Meeting/Conference (12)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (163)

•Press Release/Announcement (4)

•Special or Theme Issue (36)

•Tools/Toolkit (23)

•Web Resource (49)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (161)

•Active Errors (114)

•Latent Errors (62)

•Near Miss (11)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (139)

•Benchmarking (123)

•Continuous Quality Improvement (29)

•Critical Pathways (31)

•Practice Guidelines (147)

•Reminders (32)

•Patient Self-Management (56)

•Six Sigma (8)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (723)

•Health Care Executives and Administrators (1018)

•Non-Health Care Professionals (413)

•Patients (99)

Setting of Care

•Hospitals (770)

•Psychiatric Facilities (3)

•Residential Facilities (17)

•Ambulatory Care (93)

•Outpatient Surgery (16)

•Patient Transport (4)

1 - 20 of 1190

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NEWSPAPER/MAGAZINE ARTICLE

AHRQ presses on: no rule yet, but agency taps 10 safety organizations.

DerGurahain J. Mod Healthc. November 10, 2008;38:8.

BOOK/REPORT

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.

NEWSPAPER/MAGAZINE ARTICLE

Fixing relationships, preventing errors.

McGinn P, Chabon R. HHN Magazine Online. November 25, 2008.

STUDY

Hospital governance and the quality of care.

Jha AK, Epstein AM. Health Aff (Millwood). 2010;29:182-187.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals boost patients' power as advisers.

Landro L. Wall Street Journal. August 8, 2007:D1.

NEWSPAPER/MAGAZINE ARTICLE

Could it happen here? Learning from other organizations' safety errors.

Conway J. Healthc Exec. November/December 2008;23:64-67.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2010;15:1-4.

COMMENTARY

Assessing hospital safety on nights and weekends: the SWAN tool.

Shulkin DJ. J Patient Saf. 2009;5:75-78.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

NEWSPAPER/MAGAZINE ARTICLE

The pursuit of perfection: hospitals take heightened actions to reduce adverse events.

May EL. Healthc Exec. 2012;27:26-28,30-33.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2010.

Oakbrook Terrace, IL: The Joint Commission; September 2010.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

COMMENTARY

The ongoing quality improvement journey: next stop, high reliability.

Chassin MR, Loeb JM. Health Aff (Millwood). 2011;30:559-568.

AWARD RECIPIENT

Announcing 2009 Leapfrog top hospitals.

Washington, DC: Leapfrog Group; December 4, 2009.

MULTI-USE WEBSITE

BOOSTing Care Transitions Resource Room.

Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.

BOOK/REPORT

IBEAS: A Pioneer Study on Patient Safety in Latin America: Towards Safer Hospital Care.

Geneva, Switzerland: World Health Organization; 2011.

COMMENTARY

A framework for patient safety: a defense nuclear industry-based high-reliability model.

Birnbach DJ, Rosen LF, Williams L, Fitzpatrick M, Lubarsky DA, Menna JD. Jt Comm J Qual Patient Saf. 2013;39:233-240.

BOOK/REPORT

Health Care Leaders Action Guide: Hospital Strategies for Reducing Preventable Mortality.

Chicago, IL: Health Research & Educational Trust; March 2011.

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