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 (42)

•Identification Errors (37)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (274)

•Medical Complications (161)

•Nonsurgical Procedural Complications (33)

•Surgical Complications (126)

•Transfusion Complications (7)

•Psychological and Social Complications (24)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (740)

•Legislation/Regulation (22)

•Meeting/Conference (13)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (122)

•Press Release/Announcement (6)

•Special or Theme Issue (41)

•Tools/Toolkit (15)

•Web Resource (34)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (149)

•Active Errors (124)

•Latent Errors (58)

•Near Miss (15)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (136)

•Benchmarking (99)

•Continuous Quality Improvement (29)

•Critical Pathways (43)

•Practice Guidelines (128)

•Reminders (17)

•Patient Self-Management (49)

•Six Sigma (11)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (668)

•Health Care Executives and Administrators (996)

•Non-Health Care Professionals (415)

•Patients (55)

Setting of Care

•Hospitals (651)

•Psychiatric Facilities (5)

•Residential Facilities (15)

•Ambulatory Care (72)

•Outpatient Surgery (10)

•Patient Transport (7)

1 - 20 of 1122

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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 model for developing high-reliability teams.

Riley W, Davis SE, Miller KK, McCullough M. J Nurs Manag. 2010;18:556-563.

REVIEW

Fall prevention in hospitals: an integrative review.

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

STUDY

Strategies used by critical care nurses to identify, interrupt, and correct medical errors.

Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Am J Crit Care. 2010;19:500-509.

COMMENTARY

On the scene at Children's Hospitals and Clinics of Minnesota.

Malone G, Akre M, Hauck M. Nurs Adm Q. 2009;33:54-61.

STUDY

Adoption of National Quality Forum safe practices by magnet hospitals.

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

TOOLKIT

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.

STUDY

A secondary care nursing perspective on medication administration safety.

McBride-Henry K, Foureur M. J Adv Nurs. 2007;60:58-66.

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.

COMMENTARY

Leading your organization to high reliability.

Kemper C, Boyle DK. Nurs Manage. April 2009;40:14-18.

SPECIAL OR THEME ISSUE

Risk, Safety and Reliability Special Issue.

Newbold D, Attree M, eds. J Nurs Manag. 2009;17:145-266.

SPECIAL OR THEME ISSUE

Nurses Transforming Care.

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

COMMENTARY

A plan for achieving significant improvement in patient safety.

Johnson K, Maultsby CC. J Nurs Care Qual. 2007;22:164-171.

NEWSPAPER/MAGAZINE ARTICLE

High-reliability organizations (HROs): What they know that we don't (Part II).

ISMP Medication Safety Alert! Acute Care Edition. July 28, 2005;10:1-3.

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.

REVIEW

Patient safety: Part II. Opportunities for improvement in patient safety.

Elston DM, Stratman E, Johnson-Jahangir H, et al. J Am Acad Dermatol. 2009;61:193-205.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

STUDY

Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education.

Christiansen A, Robson L, Griffith-Evans C. J Nurs Manag. 2010;18:782-788.

SPECIAL OR THEME ISSUE

Patient Safety and Quality.

Lyndon A, Simpson KR, Bakewell-Sachs S, eds. J Perinat Neonat Nurs. 2010;24:1-89.

STUDY

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.

Vogus TJ, Sutcliffe KM. Med Care. 2007;45:997-1002.

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