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 (44)

•Diagnostic Errors (44)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (127)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (235)

•Medical Complications (99)

•Nonsurgical Procedural Complications (27)

•Surgical Complications (88)

•Transfusion Complications (7)

•Psychological and Social Complications (17)

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•Asia (4)

•Australia and New Zealand (9)

Resource Types

•Clinical Guideline (2)

•Journal Article (511)

•Legislation/Regulation (23)

•Meeting/Conference (8)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (122)

•Press Release/Announcement (1)

•Special or Theme Issue (30)

•Tools/Toolkit (14)

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Error Types

•Epidemiology of Errors and Adverse Events (89)

•Active Errors (103)

•Latent Errors (48)

•Near Miss (14)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (62)

•Benchmarking (26)

•Continuous Quality Improvement (7)

•Critical Pathways (29)

•Practice Guidelines (137)

•Reminders (20)

•Patient Self-Management (26)

•Six Sigma (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (497)

•Nursing (112)

•Pharmacy (63)

Target Audience

•Health Care Providers (562)

•Health Care Executives and Administrators (686)

•Non-Health Care Professionals (233)

•Patients (56)

Setting of Care

•Hospitals (481)

•Psychiatric Facilities (5)

•Residential Facilities (13)

•Ambulatory Care (60)

•Outpatient Surgery (8)

•Patient Transport (6)

1 - 20 of 833

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STUDY

Skilful anticipation: maternity nurses' perspectives on maintaining safety.

Lyndon A. Qual Saf Health Care. 2010;19:e8.

COMMENTARY

Perinatal patient safety and quality.

Simpson KR. J Perinat Neonatal Nurs. 2011;25:103-107.

STUDY

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

COMMENTARY

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

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

REVIEW

Perinatal high reliability.

Knox GE, Simpson KR. Am J Obstet Gynecol. 2011;204: 373-377.

SPECIAL OR THEME ISSUE

Patient Safety and Quality.

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

ORGANIZATIONAL POLICY/GUIDELINES

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.

AORN J. 2006;84:276-278, 280-283.

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.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

COMMENTARY

Failure to Latch

Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

STUDY

Managing the care of patients discharged from home health: a quiet threat to patient safety?

Flynn L. Home Healthc Nurse. 2007;25:184-190.

REVIEW

Changing practice to improve patient safety and quality of care in perinatal medicine.

Kaplan HC, Ballard J. Am J Perinatol. 2012;29:35-42.

COMMENTARY

A system-wide initiative to prevent retained vaginal sponges.

Chagolla BA, Gibbs VC, Keats JP, Pelletreau B. MCN Am J Matern Child Nurs. 2011;36:312-317.

COMMENTARY

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety.

Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Am J Obstet Gynecol. 2008;199:105.e1-e7.

STUDY

Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.

Larson EL, Cimiotti J, Haas J, et al. Arch Pediatr Adolesc Med. 2005;159:377-383.

NEWSPAPER/MAGAZINE ARTICLE

State: nurse error caused death.

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

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.

MULTI-USE WEBSITE

Nursing Care Quality at NQF.

National Quality Forum.

COMMENTARY

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

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

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