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 (42)

•Diagnostic Errors (34)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (212)

•Medical Complications (127)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (92)

•Transfusion Complications (9)

•Psychological and Social Complications (15)

Origin/Sponsor

•Africa (2)

•Asia (5)

•Australia and New Zealand (6)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (532)

•Legislation/Regulation (17)

•Meeting/Conference (11)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (128)

•Press Release/Announcement (5)

•Special or Theme Issue (30)

•Tools/Toolkit (17)

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Error Types

•Epidemiology of Errors and Adverse Events (116)

•Active Errors (72)

•Latent Errors (36)

•Near Miss (9)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (68)

•Benchmarking (78)

•Continuous Quality Improvement (18)

•Critical Pathways (19)

•Practice Guidelines (87)

•Reminders (14)

•Patient Self-Management (28)

•Six Sigma (6)

Clinical Areas

•Allied Health Services (4)

•Medicine (514)

•Nursing (49)

•Pharmacy (56)

Target Audience

•Health Care Providers (562)

•Health Care Executives and Administrators (826)

•Non-Health Care Professionals (318)

•Patients (78)

Setting of Care

•Hospitals (528)

•Psychiatric Facilities (3)

•Residential Facilities (15)

•Ambulatory Care (57)

•Outpatient Surgery (13)

•Patient Transport (7)

1 - 20 of 922

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BOOK/REPORT

Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety.

Boston, MA: Institute for Healthcare Improvement; 2005.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.

NEWSPAPER/MAGAZINE ARTICLE

Leadership practices to advance patient safety.

Crowley JD, Deen JB. Patient Saf Qual Healthc. May/June 2009;6:18-22.

STUDY

Exploring strategies for reducing hospital errors.

McFadden KL, Stock GN, Gowen CR III. J Healthc Manag. 2006;51:123-136.

NEWSPAPER/MAGAZINE ARTICLE

Global goal: reduce medical errors.

Szabo L. USA Today. August 23, 2005.

BOOK/REPORT

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

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

STUDY

Relationship between Leapfrog Safe Practices Survey and outcomes in trauma.

Glance LG, Dick AW, Osler TM, et al. Arch Surg. 2011;146:1170-1177.

COMMENTARY classic

Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response].

Wachter RM, Pronovost PJ. [Reply: Berwick DM, Hackbarth AD, McCannon CJ]. Jt Comm J Qual Patient Saf. 2006;32:621-627, 628-633.

COMMENTARY classic

Accountability measures—using measurement to promote quality improvement.

Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. N Engl J Med. 2010;363:683-688.

STUDY

Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN).

Elder NC, Graham D, Brandt E, Hickner J. J Am Board Fam Med. 2007;20:115-123.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals' bid to heal selves saves thousands.

P-I Staff and News Services. Seattle Post-Intelligencer. June 15, 2006:A1.

BOOK/REPORT classic

Patient Safety in Emergency Medicine.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

COMMENTARY

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Kavanagh KT. Soc Work Public Health. 2011;26:524-541.

COMMENTARY

Rolling out the rapid response team.

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

NEWSPAPER/MAGAZINE ARTICLE

Beware of basal opioid infusions with PCA therapy.

ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Arresting death: saving 100,000 lives.

Meyers S. Trustee. January 2007;60:6-10.

COMMENTARY

Findings of the first consensus conference on medical emergency teams.

Devita MA, Bellomo R, Hillman K, et al. Crit Care Med. 2006;34;2463-2478.

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