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 (38)

•Diagnostic Errors (37)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (46)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (172)

•Medical Complications (91)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (101)

•Transfusion Complications (6)

•Psychological and Social Complications (14)

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Resource Types

•Clinical Guideline (4)

•Journal Article (477)

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•Newspaper/Magazine Article (116)

•Press Release/Announcement (2)

•Special or Theme Issue (28)

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Error Types

•Epidemiology of Errors and Adverse Events (80)

•Active Errors (62)

•Latent Errors (29)

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Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (43)

•Benchmarking (52)

•Continuous Quality Improvement (15)

•Critical Pathways (23)

•Practice Guidelines (97)

•Reminders (12)

•Patient Self-Management (10)

•Six Sigma (3)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (509)

•Health Care Executives and Administrators (646)

•Non-Health Care Professionals (254)

•Patients (52)

Setting of Care

•Hospitals (445)

•Psychiatric Facilities (3)

•Residential Facilities (8)

•Ambulatory Care (49)

•Outpatient Surgery (7)

•Patient Transport (3)

1 - 20 of 803

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COMMENTARY

Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture.

Campbell DA Jr, Thompson M. Am J Med Qual. 2007;22:26-33.

SPECIAL OR THEME ISSUE

First, Do No Harm.

Ganguli I, ed. Virtual Mentor. 2011;13:587-678.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.

COMMENTARY

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

Singh R, Naughton B, Taylor JS, et al. Med Educ. 2005;39:1195-1204.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

STUDY

Hospital governance and the quality of care.

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

STUDY

Organisational culture: variation across hospitals and connection to patient safety climate.

Speroff T, Nwosu S, Greevy R, et al. Qual Saf Health Care. 2010;19:592-596.

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.

REVIEW

Defining and measuring patient safety.

Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL. Crit Care Clin. 2005;21:1-19.

COMMENTARY

A model for developing high-reliability teams.

Riley W, Davis SE, Miller KK, McCullough M. J Nurs Manag. 2010;18:556-563.

BOOK/REPORT

Addressing the quality and safety gap—parts I-II.

Princeton, NJ: Robert Wood Johnson Foundation; July 2009.

COMMENTARY classic

Accidental deaths, saved lives, and improved quality.

Brennan TA, Gawande A, Thomas E, Studdert D. N Engl J Med. 2005;353:1405-1409.

STUDY

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units.

Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. BMC Health Serv Res. 2005;5:28.

STUDY

Residents report on adverse events and their causes.

Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Arch Intern Med. 2005;165:2607-2613.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

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

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

BOOK/REPORT

Reducing Colorectal Surgical Site Infections.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

COMMENTARY

Advancing nursing home quality through quality improvement itself.

Werner RM, Konetzka RT. Health Aff (Millwood). 2010;29:81-86.

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