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 (51)

•Diagnostic Errors (59)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (91)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (279)

•Medical Complications (150)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (119)

•Transfusion Complications (9)

•Psychological and Social Complications (18)

Origin/Sponsor

•Africa (1)

•Asia (10)

•Australia and New Zealand (12)

Resource Types

•Clinical Guideline (4)

•Journal Article (649)

•Legislation/Regulation (28)

•Meeting/Conference (8)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (159)

•Press Release/Announcement (3)

•Special or Theme Issue (31)

•Tools/Toolkit (23)

•Web Resource (35)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (136)

•Active Errors (119)

•Latent Errors (56)

•Near Miss (13)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (100)

•Benchmarking (99)

•Continuous Quality Improvement (20)

•Critical Pathways (34)

•Practice Guidelines (184)

•Reminders (28)

•Patient Self-Management (37)

•Six Sigma (7)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (697)

•Health Care Executives and Administrators (853)

•Non-Health Care Professionals (318)

•Patients (89)

Setting of Care

•Hospitals (707)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (109)

•Outpatient Surgery (15)

•Patient Transport (3)

1 - 20 of 1074

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SPECIAL OR THEME ISSUE

Medical errors and safety systems.

Pearlman MD, ed. Clin Obstet Gynecol. 2010;53:471-585.

COMMENTARY

Patient safety in obstetrics and gynecology: an agenda for the future.

Pearlman MD. Obstet Gynecol. 2006;108:1266-1271.

SPECIAL OR THEME ISSUE

Obstetric Quality and Safety.

J Healthc Qual. 2009;31:3-52.

COMMENTARY

Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory.

Tamuz M, Harrison MI. Health Serv Res. 2006;41:1654-1676.

MULTI-USE WEBSITE

ACOG SCOPE: Safety Certification in Outpatient Practice Excellence for Women's Health.

American Congress of Obstetricians and Gynecologists.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

COMMENTARY classic

Five years after 'To Err is Human': what have we learned?

Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.

BOOK/REPORT classic

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition.

Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #464: patient safety in the surgical environment.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:786-790.

COMMENTARY classic

Is hospital patient care becoming safer? A conversation with Lucian Leape.

Buerhaus PI. Health Affairs. 2007;26:w687-w696.

NEWSPAPER/MAGAZINE ARTICLE

Standardizing safety.

Meyers S. Trustee. July/August 2006;59:12, 14, 21.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

Identifying organizational cultures that promote patient safety.

Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #546: tracking and reminder systems.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2012;120:1535-1537.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

COMMENTARY

Journey to no preventable risk: The Baylor Health Care System patient safety experience.

Kennerly D, Richter KM, Good V, Compton J, Ballard DJ. Am J Med Qual. 2011;26:43-52.

COMMENTARY

As she lay dying: how I fought to stop medical errors from killing my mom.

Welch JR. Health Aff (Millwood). 2012;31:2817-2820.

STUDY

Impact of a comprehensive patient safety strategy on obstetric adverse events.

Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009 May;200:492.e1-8.

NEWSPAPER/MAGAZINE ARTICLE

Spike in MR imaging accidents underscores need for regulation.

Radiological Society of North America. RSNA News; October 2010.

MEASUREMENT TOOL/INDICATOR

The Physician Practice Patient Safety Assessment.

Medical Group Management Association Center for Research, Health Research and Educational Trust, Institute for Safe Medication Practices. 2005.

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