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 (57)

•Diagnostic Errors (63)

•Identification Errors (48)

•Discontinuities, Gaps, and Hand-Off Problems (84)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (265)

•Medical Complications (127)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (135)

•Transfusion Complications (9)

•Psychological and Social Complications (16)

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•Asia (11)

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•Clinical Guideline (5)

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Error Types

•Epidemiology of Errors and Adverse Events (242)

•Active Errors (131)

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Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (111)

•Benchmarking (59)

•Continuous Quality Improvement (16)

•Critical Pathways (29)

•Practice Guidelines (165)

•Reminders (32)

•Patient Self-Management (24)

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Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (652)

•Health Care Executives and Administrators (787)

•Non-Health Care Professionals (269)

•Patients (65)

Setting of Care

•Hospitals (552)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (82)

•Outpatient Surgery (18)

•Patient Transport (7)

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REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

NEWSLETTER/JOURNAL

Laboratory Errors & Patient Safety.

Seattle, WA: Medical Training Solutions.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

Patient safety concerns arising from test results that return after hospital discharge.

Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.

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.

STUDY

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

Wagar EA, Stankovic AK, Raab S, Nakhleh RE, Walsh MK. Arch Pathol Lab Med. 2008;132:1617-1622.

COMMENTARY classic

Errors in laboratory medicine: practical lessons to improve patient safety.

Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.

COMMENTARY

Putting power into patient safety: interventions.

Astion M. Laboratory Errors & Patient Safety. May-June 2005;1:5-8.

STUDY

Frequency of failure to inform patients of clinically significant outpatient test results.

Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.

STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

NEWSPAPER/MAGAZINE ARTICLE

Follow-up tips for a safe, efficient practice.

Weiss GG. Med Econ. May 19, 2006; 83:47-49.

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

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

STUDY

Preventable morbidity at a mature trauma center.

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

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

Residents report on adverse events and their causes.

Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Arch Intern Med. 2005;165:2607-2613.

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.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

STUDY

Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure."

Covinsky KE, Pierluissi E, Johnston CB. JAMA. 2011;306:1782-1793.

STUDY

Medication prescribing errors involving the route of administration.

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

STUDY

Surgical confusions in ophthalmology.

Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.

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