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 (62)

•Identification Errors (53)

•Discontinuities, Gaps, and Hand-Off Problems (114)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (341)

•Medical Complications (214)

•Nonsurgical Procedural Complications (39)

•Surgical Complications (208)

•Transfusion Complications (7)

•Psychological and Social Complications (29)

Origin/Sponsor

•Africa (1)

•Asia (14)

•Australia and New Zealand (27)

•Central and South America (2)

•Europe (150)

•North America (1111)

Resource Types

•Clinical Guideline (8)

•Journal Article (836)

•Legislation/Regulation (33)

•Meeting/Conference (13)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (151)

•Press Release/Announcement (8)

•Special or Theme Issue (46)

•Tools/Toolkit (22)

•Web Resource (59)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (213)

•Active Errors (180)

•Latent Errors (67)

•Near Miss (18)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (194)

•Benchmarking (94)

•Continuous Quality Improvement (27)

•Critical Pathways (59)

•Practice Guidelines (214)

•Reminders (33)

•Patient Self-Management (73)

•Six Sigma (10)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (927)

•Health Care Executives and Administrators (1140)

•Non-Health Care Professionals (421)

•Patients (92)

Setting of Care

•Hospitals (808)

•Psychiatric Facilities (5)

•Residential Facilities (20)

•Ambulatory Care (102)

•Outpatient Surgery (26)

•Patient Transport (6)

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COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

MULTI-USE WEBSITE

Council on Surgical and Perioperative Safety.

Council on Surgical and Perioperative Safety; 633 N. St. Clair St. Chicago, IL, 60611.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

COMMENTARY

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

Russell TR. Surg Today. 2009;39:739-745.

STUDY

A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. J Surg Res. 2009;153:95-104.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

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

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

COMMENTARY

Perfusion safety: new initiatives and enduring principles.

Kurusz M. Perfusion. 2011;26(suppl 1):6-14.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

STUDY

Identifying opportunities for quality improvement in surgical site infection prevention.

Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.

MULTI-USE WEBSITE

Nora Institute for Surgical Patient Safety.

American College of Surgeons.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

STUDY

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

NEWSPAPER/MAGAZINE ARTICLE

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

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

SPECIAL OR THEME ISSUE

Enhancing Surgical Systems.

Healey AN, Catchpole K, Yule S. Cogn Tech Work. 2008;10:249-333.

STUDY

Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3?

Meeks DW, Lally KP, Carrick MM, et al. Am J Surg. 2011;201:76-83.

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