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 (69)

•Diagnostic Errors (53)

•Identification Errors (37)

•Discontinuities, Gaps, and Hand-Off Problems (91)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (372)

•Medical Complications (158)

•Nonsurgical Procedural Complications (38)

•Surgical Complications (148)

•Transfusion Complications (8)

•Psychological and Social Complications (17)

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (26)

•Central and South America (1)

•Europe (107)

•North America (1053)

Resource Types

•Clinical Guideline (7)

•Journal Article (786)

•Legislation/Regulation (32)

•Meeting/Conference (14)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (148)

•Press Release/Announcement (15)

•Special or Theme Issue (36)

•Tools/Toolkit (20)

•Web Resource (38)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (188)

•Active Errors (153)

•Latent Errors (55)

•Near Miss (16)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (154)

•Benchmarking (81)

•Continuous Quality Improvement (25)

•Critical Pathways (42)

•Practice Guidelines (231)

•Reminders (35)

•Patient Self-Management (51)

•Six Sigma (11)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (801)

•Health Care Executives and Administrators (1044)

•Non-Health Care Professionals (417)

•Patients (74)

Setting of Care

•Hospitals (685)

•Psychiatric Facilities (4)

•Residential Facilities (17)

•Ambulatory Care (97)

•Outpatient Surgery (18)

•Patient Transport (6)

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STUDY

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:725-728.

NEWSPAPER/MAGAZINE ARTICLE

Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations.

Hall J. The Free Lance-Star. September 25, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

FACT SHEET/FAQS

Medication safety issue brief. Counterfeit drug prevention and identification.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

STUDY

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

Garbutt J, Milligan PE, McNaughton C, Waterman BM, Dunagan CW, Fraser VJ. J Patient Saf. 2005;1:195-200.

STUDY

Medication prescribing errors involving the route of administration.

Lesar TS. Hosp Pharm. 2006;41:1053-1066.

TOOLKIT

ISMP and FDA campaign to eliminate use of error-prone abbreviations.

Huntington Valley, PA: Institute for Safe Medication Practices.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

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.

COMMENTARY

Collegiality vs. Competence

Sagin T. AHRQ WebM&M [serial online]. March 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:675-679.

STUDY

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Qual Saf Health Care. 2006;15:89-91.

NEWSPAPER/MAGAZINE ARTICLE

"Near injury" alters procedures at Virginia Mason.

Ostrom CM. The Seattle Times. May 21, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Death by handwriting.

Glabman M. Trustee. October 2005;58:29-32.

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

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

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