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 (74)

•Diagnostic Errors (51)

•Identification Errors (30)

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

•Fatigue and Sleep Deprivation (7)

•Medication Safety (282)

•Medical Complications (221)

•Nonsurgical Procedural Complications (39)

•Surgical Complications (117)

•Transfusion Complications (9)

•Psychological and Social Complications (26)

Origin/Sponsor

•Africa (3)

•Asia (10)

•Australia and New Zealand (13)

•Central and South America (2)

•Europe (113)

•North America (1061)

Resource Types

•Clinical Guideline (4)

•Journal Article (712)

•Legislation/Regulation (30)

•Meeting/Conference (12)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (168)

•Press Release/Announcement (7)

•Special or Theme Issue (41)

•Tools/Toolkit (27)

•Web Resource (54)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (152)

•Active Errors (112)

•Latent Errors (62)

•Near Miss (9)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (124)

•Benchmarking (141)

•Continuous Quality Improvement (30)

•Critical Pathways (43)

•Practice Guidelines (180)

•Reminders (25)

•Patient Self-Management (54)

•Six Sigma (8)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (746)

•Health Care Executives and Administrators (1054)

•Non-Health Care Professionals (419)

•Patients (102)

Setting of Care

•Hospitals (787)

•Psychiatric Facilities (4)

•Residential Facilities (20)

•Ambulatory Care (85)

•Outpatient Surgery (19)

•Patient Transport (5)

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BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

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.

REVIEW

Perinatal high reliability.

Knox GE, Simpson KR. Am J Obstet Gynecol. 2011;204: 373-377.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

BOOK/REPORT

Improving the Reliability of Health Care.

Nolan T, Resar R, Haraden C, Griffin FA. Boston, MA: Institute for Healthcare Improvement; 2004.

STUDY

Identifying organizational cultures that promote patient safety.

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

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Ventilator-associated pneumonia—the wrong quality measure for benchmarking.

Klompas M, Platt R. Ann Intern Med. 2007;147:803-805.

STUDY

Explaining Michigan: developing an ex post theory of a quality improvement program.

Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.

STUDY

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.

STUDY

How event reporting by US hospitals has changed from 2005 to 2009.

Farley DO, Haviland A, Haas A, Pham C, Munier WB, Battles JB. BMJ Qual Saf. 2012;21:70-77.

COMMENTARY

Using a logic model to design and evaluate quality and patient safety improvement programs.

Goeschel CA, Weiss WM, Pronovost PJ. Int J Qual Health Care. 2012;24:330-337.

STUDY

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

AUDIOVISUAL

Hospital-acquired infections.

Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.

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