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 (76)

•Diagnostic Errors (59)

•Identification Errors (51)

•Discontinuities, Gaps, and Hand-Off Problems (103)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (344)

•Medical Complications (215)

•Nonsurgical Procedural Complications (42)

•Surgical Complications (208)

•Transfusion Complications (8)

•Psychological and Social Complications (27)

Origin/Sponsor

•Africa (2)

•Asia (16)

•Australia and New Zealand (29)

•Central and South America (3)

•Europe (147)

•North America (1111)

Resource Types

•Clinical Guideline (8)

•Journal Article (835)

•Legislation/Regulation (34)

•Meeting/Conference (13)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (150)

•Press Release/Announcement (8)

•Special or Theme Issue (43)

•Tools/Toolkit (24)

•Web Resource (58)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (213)

•Active Errors (175)

•Latent Errors (64)

•Near Miss (15)

Approach to Improving Safety
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Quality Improvement Strategies

•Audit and Feedback (193)

•Benchmarking (89)

•Continuous Quality Improvement (25)

•Critical Pathways (61)

•Practice Guidelines (222)

•Reminders (31)

•Patient Self-Management (72)

•Six Sigma (10)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (933)

•Health Care Executives and Administrators (1138)

•Non-Health Care Professionals (420)

•Patients (90)

Setting of Care

•Hospitals (799)

•Psychiatric Facilities (5)

•Residential Facilities (20)

•Ambulatory Care (97)

•Outpatient Surgery (26)

•Patient Transport (7)

1 - 20 of 1327

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COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

MULTI-USE WEBSITE

Nora Institute for Surgical Patient Safety.

American College of Surgeons.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

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

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

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.

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.

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

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

Smith ML, Raab SS. Arch Pathol Lab Med. 2011;135:1436-1440.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

STUDY

Variation in hospital mortality associated with inpatient surgery.

Ghaferi AA, Birkmeyer JD, Dimick JB. N Engl J Med. 2009;361:1368-1375.

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.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

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.

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.

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.

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.

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