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 (56)

•Diagnostic Errors (58)

•Identification Errors (39)

•Discontinuities, Gaps, and Hand-Off Problems (85)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (287)

•Medical Complications (155)

•Nonsurgical Procedural Complications (38)

•Surgical Complications (174)

•Transfusion Complications (7)

•Psychological and Social Complications (20)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (6)

•Journal Article (717)

•Legislation/Regulation (30)

•Meeting/Conference (9)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (136)

•Press Release/Announcement (6)

•Special or Theme Issue (36)

•Tools/Toolkit (17)

•Web Resource (37)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (172)

•Active Errors (125)

•Latent Errors (51)

•Near Miss (12)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (139)

•Benchmarking (69)

•Continuous Quality Improvement (20)

•Critical Pathways (41)

•Practice Guidelines (189)

•Reminders (25)

•Patient Self-Management (43)

•Six Sigma (9)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (726)

•Health Care Executives and Administrators (942)

•Non-Health Care Professionals (340)

•Patients (66)

Setting of Care

•Hospitals (636)

•Psychiatric Facilities (6)

•Residential Facilities (19)

•Ambulatory Care (102)

•Outpatient Surgery (24)

•Patient Transport (6)

1 - 20 of 1109

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NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

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

NEWSPAPER/MAGAZINE ARTICLE

Surgical errors: new products, protocols help slash the risks.

Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

Murphy K. New York Times. October 31, 2006:F5.

NEWSPAPER/MAGAZINE ARTICLE

Improving patient safety in the office: The Institute for Safety in Office-Based Surgery.

Urman RD, Shapiro FE. APSF Newsletter. 2011;3-4,9.

REVIEW

Patient safety in the operating room—part 1 and part 2.

Poore SO, Sillah NM, Mahajan AY, Gutowski KA. Plast Reconstr Surg. 2012;130:1038-1058.

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

STUDY

A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.

Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.

MULTI-USE WEBSITE

Nora Institute for Surgical Patient Safety.

American College of Surgeons.

COMMENTARY

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

Singh R, Naughton B, Taylor JS, et al. Med Educ. 2005;39:1195-1204.

COMMENTARY

The Wild West: Patient Safety in Office-Based Anesthesia

Kaushal R, Upadhyayula S, Gaba DM, Leape LL. AHRQ WebM&M [serial online]. May 2006.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

STUDY

Preventable morbidity at a mature trauma center.

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

STUDY

Medication safety infrastructure in critical-access hospitals in Florida.

Winterstein AG, Hartzema AG, Johns TE, et al. Am J Health Syst Pharm. 2006;63:442-450.

NEWSPAPER/MAGAZINE ARTICLE

State: nurse error caused death.

Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.

NEWSPAPER/MAGAZINE ARTICLE

Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.

Landro L. Wall Street Journal. July 21, 2009:D1.

STUDY

Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter?

Rosen AB, Blendon RJ, DesRoches CM, et al. Acad Med. 2005;80:189-192.

STUDY

Work-hour restrictions as an ethical dilemma for residents.

Carpenter RO, Austin MT, Tarpley JL, Griffin MR, Lomis KD. Amer J Surg. 2006;191:527-532.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

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