AHRQ Patient Safety Network

The Collection > Continuous Quality Improvement

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (3)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (4)

•Medication Safety (17)

•Medical Complications (7)

•Surgical Complications (6)

•Transfusion Complications (1)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (5)

•Europe (4)

•North America (39)

Resource Types

•Book/Report (5)

•Journal Article (40)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (4)

Error Types

•Epidemiology of Errors and Adverse Events (10)

•Active Errors (4)

•Latent Errors (7)

•Near Miss (1)

Approach to Improving Safety
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Continuous Quality Improvement

Clinical Areas

•Medicine (28)

•Nursing (4)

•Pharmacy (3)

Target Audience

•Health Care Providers (27)

•Health Care Executives and Administrators (40)

•Non-Health Care Professionals (19)

•Patients (1)

Setting of Care

•Hospitals (35)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (2)

•Outpatient Surgery (1)

•Patient Transport (2)

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REVIEW

Patient safety and error reduction in surgical pathology.

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

COMMENTARY

Medication tracers: a systems approach to medication safety.

Hendrick EC, Montanya KR, Griffith N. Hosp Pharm. 2007;42:916-920.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

STUDY

Paramedic self-reported medication errors.

Vilke GM, Tornabene SV, Stepanski B, et al. Prehosp Emerg Care. 2006;10:457-462.

STUDY

Paramedic self-reported medication errors.

Vilke GM, Tornabene SV, Stepanski B, et al. Prehosp Emerg Care. 2007;11:80-84.

STUDY

Real time patient safety audits: improving safety every day.

Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.

COMMENTARY

Patient safety in women's health care: a framework for progress.

Gluck PA. Best Pract Res Clin Obstet Gynaecol. 2007;21:525-36.

STUDY

Registration-associated patient misidentification in an academic medical center: causes and corrections.

Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.

STUDY

Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

Dunn KL, Reddy P, Moulden A, Bowes G. Arch Dis Child. 2006;91:169-172.

NEWSPAPER/MAGAZINE ARTICLE

The dawn of the robo-docs.

Weber DO. Hosp Health Netw. March 14, 2006.

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

STUDY

Rapid response teams and continuous quality improvement.

Dailey MS, Durkin S, Gulczynski B, Kearney M, Loeb B, Pouliot J. Patient Saf Qual Healthc. Nov/Dec 2009;6:28-31.

COMMENTARY

A team performance measurement model for continuous improvement.

Ciçek MC, Köksal G, Özdemirel NE. Total Qual Manag Bus Excel. 2005;16:331-349.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

COMMENTARY

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Harding AD. Am J Nurs. 2012;112:26-35.

STUDY

Organizational culture, critical success factors, and the reduction of hospital errors.

Stock GN, McFadden KL, Gowen III, CR. Int J Prod Econ. 2007;106:368–392.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

STUDY

Sins of omission. Getting too little medical care may be the greatest threat to patient safety.

Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. J Gen Intern Med. 2005;20:686-691.

COMMENTARY

Kaiser Permanente's performance improvement system, part 4: creating a learning organization.

Schilling L, Dearing JW, Staley P, Harvey P, Fahey L, Kuruppu F. Jt Comm J Qual Patient Saf. 2011;37:532-543.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007.

Oakbrook Terrace, IL: The Joint Commission; November 2007.

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