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 (82)

•Diagnostic Errors (109)

•Identification Errors (53)

•Discontinuities, Gaps, and Hand-Off Problems (164)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (385)

•Medical Complications (216)

•Nonsurgical Procedural Complications (44)

•Surgical Complications (155)

•Transfusion Complications (11)

•Psychological and Social Complications (32)

Origin/Sponsor

•Africa (2)

•Asia (18)

•Australia and New Zealand (27)

•Central and South America (3)

•Europe (146)

•North America (1204)

Resource Types

•Clinical Guideline (5)

•Journal Article (887)

•Legislation/Regulation (35)

•Meeting/Conference (13)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (178)

•Press Release/Announcement (11)

•Special or Theme Issue (40)

•Tools/Toolkit (29)

•Web Resource (64)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (224)

•Active Errors (245)

•Latent Errors (109)

•Near Miss (19)

Approach to Improving Safety
< All

Quality Improvement Strategies

•Audit and Feedback (197)

•Benchmarking (128)

•Continuous Quality Improvement (34)

•Critical Pathways (57)

•Practice Guidelines (254)

•Reminders (44)

•Patient Self-Management (97)

•Six Sigma (6)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (995)

•Health Care Executives and Administrators (1200)

•Non-Health Care Professionals (463)

•Patients (149)

Setting of Care

•Hospitals (863)

•Psychiatric Facilities (5)

•Residential Facilities (18)

•Ambulatory Care (132)

•Outpatient Surgery (23)

•Patient Transport (11)

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AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

COMMENTARY

Lethal Vertigo.

Furman JM. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

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

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

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

Eytan T. AHRQ WebM&M [serial online]. October 2008.

COMMENTARY

Undiagnosed Vaginal Bleeding.

Mandelblatt J. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

NEWSPAPER/MAGAZINE ARTICLE

Health for life. Keys to safer hospitals.

Berwick DM. Newsweek. December 12, 2005;46:75-78.

REVIEW

Missed injuries in trauma patients: a literature review.

Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.

NEWSPAPER/MAGAZINE ARTICLE

Health literacy—a quality and patient safety imperative.

Foubister V. Quality Matters. November/December 2006.

COMMENTARY

The Dropped Lung.

Heffner JE. AHRQ WebM&M [serial online]. May 2003.

STUDY

Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system.

Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-298.

STUDY

Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.

Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-346.

NEWSPAPER/MAGAZINE ARTICLE

Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.

Russell S. San Francisco Chronicle. June 24, 2006.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

STUDY

The host hospital 24-hour underreferral rate: an automated measure of call-center safety.

Hirsh DA, Simon HK, Massey R, Thornton L, Simon JE. Pediatrics. 2007;119:1139-1144.

STUDY

Tracking rates of patient safety indicators over time: lessons from the Veterans Administration.

Rosen AK, Zhao S, Rivard P, et al. Med Care. 2006;44:850-861.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals move to cut dangerous lab errors.

Landro L. Wall Street Journal (Eastern edition). June 14, 2006:D1. [Reprinted on Post-gazette.com].

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

BOOK/REPORT

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

Wisc Med J. 2006:105;1-86.

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