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 (71)

•Diagnostic Errors (46)

•Identification Errors (37)

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

•Fatigue and Sleep Deprivation (8)

•Medication Safety (366)

•Medical Complications (180)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (133)

•Transfusion Complications (8)

•Psychological and Social Complications (22)

Origin/Sponsor

•Asia (10)

•Australia and New Zealand (26)

•Central and South America (1)

•Europe (102)

•North America (1029)

Resource Types

•Clinical Guideline (5)

•Journal Article (791)

•Legislation/Regulation (28)

•Meeting/Conference (14)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (145)

•Press Release/Announcement (10)

•Special or Theme Issue (36)

•Tools/Toolkit (19)

•Web Resource (33)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (173)

•Active Errors (145)

•Latent Errors (65)

•Near Miss (13)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (162)

•Benchmarking (87)

•Continuous Quality Improvement (25)

•Critical Pathways (49)

•Practice Guidelines (187)

•Reminders (35)

•Patient Self-Management (53)

•Six Sigma (11)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (756)

•Health Care Executives and Administrators (1029)

•Non-Health Care Professionals (404)

•Patients (66)

Setting of Care

•Hospitals (693)

•Psychiatric Facilities (5)

•Residential Facilities (17)

•Ambulatory Care (86)

•Outpatient Surgery (10)

•Patient Transport (8)

1 - 20 of 1193

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STUDY

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. J Exp Psychol Appl. 2011;17:247-256.

COMMENTARY

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

STUDY

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

COMMENTARY

Rolling out the rapid response team.

Gallagher-Ford L, Fineout-Overholt E, Melnyk BM, Stillwell SB. Am J Nurs. 2011;111:42-47.

REVIEW

Inappropriate trust in technology: implications for critical care nurses.

Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.

REVIEW

Fall prevention in hospitals: an integrative review.

Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.

STUDY

Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.

Larson EL, Cimiotti J, Haas J, et al. Arch Pediatr Adolesc Med. 2005;159:377-383.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

BOOK/REPORT

Soaring to Success: Taking Crew Resource Management from the Cockpit to the Nursing Unit.

Sculli GL, Sine DM. Danvers, MA: HCPro, Inc; 2011. ISBN: 9781601467836.

COMMENTARY

Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care

Rich V. AHRQ WebM&M [serial online]. August 2009.

COMMENTARY

A performance improvement plan to increase nurse adherence to use of medication safety software.

Gavriloff C. J Pediatr Nurs. 2012;27:375-382.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

STUDY

Infants at risk: when nurse fatigue jeopardizes quality care.

Dean GE, Scott LD, Rogers AE. Adv Neonatal Care. 2006;6:120-126.

REVIEW

Quality and safety in the intensive care unit.

Stockwell DC, Slonim AD. J Intensive Care Med. 2006;21:199-210.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

STUDY

Oncology nurses' perceptions about involving patients in the prevention of chemotherapy administration errors.

Schwappach DLB, Hochreutener MA, Wernli M. Oncol Nurs Forum. 2010;37:E84-E91.

STUDY

Lessons learned: use of event reporting by nurses to improve patient safety and quality.

Hession-Laband E, Mantell P. J Pediatr Nurs. 2011;26:149-155.

STUDY

Skilful anticipation: maternity nurses' perspectives on maintaining safety.

Lyndon A. Qual Saf Health Care. 2010;19:e8.

COMMENTARY

Teaching quality improvement.

Murray ME, Douglas S, Girdley D, Jarzemsky P. J Nurs Educ. 2010;49:466-469.

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