Multidisciplinary approaches to reducing error and risk in a patient care setting.
Connor M, Ponte PR, Conway J. Crit Care Nurs Clin N Am. 2002;14:359-367.
This article describes the multifaceted response of Dana-Farber Cancer Institute after a highly publicized medication error in 1995. The authors review a series of interventions designed through the multidisciplinary efforts of nursing, pharmacy, physician, administrative, and other clinical staff. Factors discussed include the role of the patient and family, the need for executive leadership,
root cause analyses
, a shift to nonpunitive environments, and development of better processes for care. The authors share how a single
catalyzed 7 years of efforts to bring patient safety to the forefront and explain what future steps must occur in the area of patient safety.
Recommendations for Safe Use of Insulin in Hospitals.
Bethesda, MD: American Society of Health-System Pharmacists; 2006.
Nurse decision making in the prearrest period.
Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.
A model for developing high-reliability teams.
Riley W, Davis SE, Miller KK, McCullough M. J Nurs Manag. 2010;18:556-563.
What is patient safety culture? A review of the literature.
Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. J Nurs Scholarsh. 2010;42:156-165.
View all related resources...
Find Related Resources by...
Setting of Care
Approach to Improving Safety
Root Cause Analysis
Culture of Safety
United States of America
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.
Contact AHRQ PSNet
Terms & Conditions
Freedom of Information Act
The White House
USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364