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 (69)

•Diagnostic Errors (59)

•Identification Errors (36)

•Discontinuities, Gaps, and Hand-Off Problems (109)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (329)

•Medical Complications (208)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (124)

•Transfusion Complications (11)

•Psychological and Social Complications (18)

Origin/Sponsor

•Africa (1)

•Asia (15)

•Australia and New Zealand (23)

•Central and South America (1)

•Europe (112)

•North America (1056)

Resource Types

•Clinical Guideline (5)

•Journal Article (778)

•Legislation/Regulation (27)

•Meeting/Conference (8)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (149)

•Press Release/Announcement (7)

•Special or Theme Issue (36)

•Tools/Toolkit (21)

•Web Resource (40)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (203)

•Active Errors (147)

•Latent Errors (66)

•Near Miss (15)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (178)

•Benchmarking (120)

•Continuous Quality Improvement (30)

•Critical Pathways (41)

•Practice Guidelines (151)

•Reminders (27)

•Patient Self-Management (61)

•Six Sigma (9)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (746)

•Health Care Executives and Administrators (1054)

•Non-Health Care Professionals (406)

•Patients (84)

Setting of Care

•Hospitals (842)

•Psychiatric Facilities (4)

•Residential Facilities (21)

•Ambulatory Care (106)

•Outpatient Surgery (18)

•Patient Transport (6)

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BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

BOOK/REPORT

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

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

COMMENTARY

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

Marsteller JA, Holzmueller CG, Makary M, et al. Jt Comm J Qual Patient Saf. 2008;34:604-607.

STUDY

Hospital computerized provider order entry adoption and quality: an examination of the United States.

Swanson Kazley A, Diana ML. Health Care Manage Rev. 2011;36:86-94.

REVIEW

Implementing patient safety interventions in your hospital: what to try and what to avoid.

Ranji SR, Shojania KG. Med Clin North Am. 2008;92:275-293.

COMMENTARY

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.

Masica AL, Richter KM, Convery P, Haydar Z. Proc (Bayl Univ Med Cent). 2009;22:103-111.

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

Adoption of National Quality Forum safe practices by magnet hospitals.

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

MULTI-USE WEBSITE classic

Improving America's Hospitals—The Joint Commission's Annual Report on Quality and Safety.

Oakbrook Terrace, IL: Joint Commission.

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

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

COMMENTARY

Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

Clarke CM, Persaud DD. J Patient Saf. 2011;7:11-18.

MULTI-USE WEBSITE

California Hospital Patient Safety Organization.

1215 K Street, Suite 800, Sacramento, CA 95814.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Your high-alert medication list—relatively useless without associated risk-reduction strategies.

ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.

REVIEW

Fall prevention in hospitals: an integrative review.

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

NEWSPAPER/MAGAZINE ARTICLE

The pursuit of perfection: hospitals take heightened actions to reduce adverse events.

May EL. Healthc Exec. 2012;27:26-28,30-33.

BOOK/REPORT

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

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.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

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