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 (67)

•Diagnostic Errors (51)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (138)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (432)

•Medical Complications (177)

•Nonsurgical Procedural Complications (38)

•Surgical Complications (132)

•Transfusion Complications (8)

•Psychological and Social Complications (16)

Origin/Sponsor

•Asia (16)

•Australia and New Zealand (29)

•Central and South America (1)

•Europe (114)

•North America (1070)

Resource Types

•Clinical Guideline (5)

•Journal Article (810)

•Legislation/Regulation (30)

•Meeting/Conference (11)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (154)

•Press Release/Announcement (11)

•Special or Theme Issue (42)

•Tools/Toolkit (26)

•Web Resource (35)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (262)

•Active Errors (158)

•Latent Errors (60)

•Near Miss (14)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (182)

•Benchmarking (79)

•Continuous Quality Improvement (24)

•Critical Pathways (50)

•Practice Guidelines (228)

•Reminders (39)

•Patient Self-Management (64)

•Six Sigma (14)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (831)

•Health Care Executives and Administrators (1059)

•Non-Health Care Professionals (366)

•Patients (74)

Setting of Care

•Hospitals (734)

•Psychiatric Facilities (5)

•Residential Facilities (19)

•Ambulatory Care (107)

•Outpatient Surgery (14)

•Patient Transport (9)

1 - 20 of 1252

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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.

COMMENTARY

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

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

COMMENTARY

Implementing a systematic response to medication errors.

Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.

COMMENTARY

Teaching quality improvement.

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

STUDY

Adoption of National Quality Forum safe practices by magnet hospitals.

Jayawardhana J, Welton JM, Lindrooth R. J Nurs Adm. 2011;41:350-356.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

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.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

SPECIAL OR THEME ISSUE

Nurses Transforming Care.

Am J Nurs. 2009;109(suppl 11):3-80, C3.

COMMENTARY

Medication errors: don't let them happen to you.

Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.

COMMENTARY

Implementing AORN recommended practices for medication safety.

Hicks RW, Wanzer LJ, Denholm B. AORN J. 2012;96:605-622.

COMMENTARY

Bringing change-of-shift report to the bedside: a patient- and family-centered approach.

Griffin T. J Perinat Neonatal Nurs. 2010;24:348-353.

REVIEW

Nursing handoffs: a systematic review of the literature.

Riesenberg LA, Leisch J, Cunningham JM. Am J Nurs. 2010;110:24-34.

STUDY

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

Fore AM, Sculli GL, Albee D, Neily J. J Nurs Manag. 2013;21:106-111.

REVIEW

Fall prevention in hospitals: an integrative review.

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

MULTI-USE WEBSITE

Nursing Care Quality at NQF.

National Quality Forum.

STUDY

Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents.

Bertsche T, Bertsche A, Krieg EM, et al. Qual Saf Health Care. 2010;19:e26.

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.

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