AHRQ Patient Safety Network

The Collection > Forcing Functions

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•Device-related Complications (6)

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•Identification Errors (4)

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

•Medication Safety (16)

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•Epidemiology of Errors and Adverse Events (7)

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Approach to Improving Safety
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Forcing Functions

Clinical Areas

•Allied Health Services (2)

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•Health Care Providers (28)

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•Hospitals (25)

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1 - 20 of 38

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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

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

REVIEW

Enteral feeding misconnections: an update.

Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

COMMENTARY

Eptifibatide Epilogue

Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.

STUDY

Management of test results in family medicine offices.

Elder NC, McEwen TR, Flach JM, Gallimore JJ. Ann Fam Med. 2009;7:343-351.

COMMENTARY

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

Evans AS, Lazar EJ, Tiase VL, et al. Am J Med Qual. 2011;26:39-42.

MEETING/CONFERENCE PROCEEDINGS

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

COMMENTARY

Use of the common gas outlet for supplementary oxygen during Caesarean section.

Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.

STUDY

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Staying safe: simple tools for safe surgery.

Karl RC. Bull Am Coll Surg. April 2007;92:16-22.

STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

COMMENTARY

Checklists to reduce diagnostic errors.

Ely JW, Graber ML, Croskerry P. Acad Med. 2011;86:307-313.

REVIEW

Requirements for the design and implementation of checklists for surgical processes.

Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Surg Endosc. 2009;23:715-726.

COMMENTARY

Mistake-proofing healthcare: why stopping processes may be a good start.

Grout JR, Toussaint JS. Bus Horiz. 2010;53:149-156.

COMMENTARY

Applying the Toyota Production System: using a patient safety alert system to reduce error.

Furman C, Caplan R. Jt Comm J Qual Patient Saf. 2007;33:376-386.

COMMENTARY

A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.

Tarpey K, Schaaf E, Lakhani U, Balcitis J. Jt Comm J Qual Patient Saf. 2010;36:461-467.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

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