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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
Date Created: May 4, 2023
Last Updated: May 17, 2025
Description
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Library Organization
Custom - This library is organized by custom section header names.
Foundations (7)
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well as common mistakes and pitfalls at each of the stages. These mistakes include not... Read More
Berwick D. New Engl J Med. 1989;320:53-56.
Two approaches to improving quality in health care are illustrated in this article. The first, called quality by inspection, is a system based on the belief that quality is best achieved by removing... Read More
Burnett S, Benn J, Pinto A, et al. Qual Saf Health Care. 2010;19:313-7.
Implementation of large-scale safety improvement programs requires learning organizations—organizations with the capacity... Read More
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Influences (9)
Verma AA, Trbovich PL, Mamdani MM, et al. BMJ Qual Saf. 2024;33:121-131.
Artificial intelligence and machine learning present both opportunities and threats to patient safety. This article... Read More
Akins RB, Cole BR. J Patient Saf. 2005;1(1):9-16.
In order to develop a strategic plan to address patient safety issues, this study sought a national perspective to outline targets... Read More
Ranji SR, Shojania KG. Med Clin North Am. 2008;92:275-93, vii-viii.
Patient safety improvement initiatives are often chosen in the context of an existing tension between taking an evidence-based approach versus a practical one... Read More
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Process (6)
Hampton S, Murray J, Lawton R, et al. BMJ Qual Saf. 2025;34:92-99.
Transitions of care between the hospital and home can jeopardize patient... Read More
Guerra-Paiva S, Lobão MJ, Simões DG, et al. BMJ Open. 2023;13:e078118.
Many clinicians experience emotional and/or psychological distress after involvement in an... Read More
Rogers G, Alper E, Brunelle D, et al. Jt Comm J Qual Patient Saf. 2016;32:37-50.
Medication reconciliation is a targeted National Patient Safety Goal. This study describes the experiences of 50 Massachusetts hospitals that... Read More
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All Library Content (23)
Hampton S, Murray J, Lawton R, et al. BMJ Qual Saf. 2025;34(2):92-99.
Transitions of care between the hospital and home can jeopardize patient safety for a myriad of reasons, such as communication gaps and poor care coordination. This article evaluates the implementation of hybrid “Your Care Needs You” (YCNY) intervention in the UK’s National Health Services (NHS), which aims to improve the safety of care transitions from hospital to home by supporting patients in (1) managing health and well-being, (2) medication management, (3) completing activities of daily living, and (4) anticipating needs and escalating care. Qualitative evaluations and observations found that YCNY goals resonated with patients, but that implementation was often hampered by time constraints and understaffing.
Verma AA, Trbovich PL, Mamdani MM, et al. BMJ Qual Saf. 2024;33(2):121-131.
Artificial intelligence and machine learning present both opportunities and threats to patient safety. This article highlights machine learning applications in quality improvement and patient safety (e.g., decision support) and practice considerations before deploying machine learning applications (e.g., presence of underlying biases). The authors provide several recommendations for optimizing implementation of machine learning applications in healthcare settings.
Guerra-Paiva S, Lobão MJ, Simões DG, et al. BMJ Open. 2023;13(12):e078118.
Many clinicians experience emotional and/or psychological distress after involvement in an adverse event. This scoping review of 29 articles identified several factors supporting successful implementation of programs to support healthcare workers involved in patient safety incidents, including a non-punitive organizational culture and strong leadership engagement. The review also highlights the importance of peer support training and resource allocation (e.g., funding, protected time) to ensure program sustainability.
Special or Theme Issue
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2025.
Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving "Elements" series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, measuring improvement, and learning health systems. The reports align with the strategic efforts of the THIS.Institute (The Healthcare Improvement Studies Institute) aiming to improve health care through the creation of effective implementable evidence.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2023;28(1):50-57.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Conner T, Unsworth J, Machin A. J Nurs Manag. 2020;28(5):1134-1143.
Using qualitative methods, this article synthesizes feedback from interviews and focus groups with hospital leadership and healthcare workers (e.g., executives, charge nurses, staff nurses) about the implementation of safety initiatives at one UK hospital and discusses the importance of positive reinforcement across all levels of an organization for their successful implementation.
Braithwaite J, Marks D, Taylor N. Int J Qual Health Care. 2014;26(3):321-329.
Implementation science studies methods to promote integration of research findings and evidence into health care policy and practice. This systematic review examined which aspects of new safety practice implementations led to actual improvement. Researchers found that enhanced safety was associated with preparation for change, personnel capacity, and organizational receptiveness to change. Features of successful implementation efforts included change management fundamentals such as planning, teamwork, having champions, and tailoring to local context. This study sheds light on the well-known lag in translating research into practice, an under-studied but critical aspect of improving patient safety. A recent AHRQ WebM&M perspective discusses implementation of evidence-based practices and future avenues for patient safety research.
Hull L, Athanasiou T, Russ S. Ann Surg. 2017;265(6):1104-1112.
Implementation science is utilized to understand how to apply research into practice. This review explores the use of implementation science in surgical patient safety initiatives to enable the translation of research into active care. The authors focus their discussion on the widely implemented World Health Organization surgical checklist to identify factors that drive and sustain improvement, including context, implementation strategies, and outcomes.
Rockville, MD: Agency for Healthcare Research and Quality; October 2004.
This AHRQ-funded Partnerships in Implementing Patient Safety (PIPS) project report presents an implementation structure for medication safety and safety culture development in small rural hospitals.
Wiegmann DA. Ann Surg. 2016;263(1):9-11.
Improvement efforts often face challenges associated with implementation and adherence, for example, the difficulty of engaging surgeons and other clinicians in checklist interventions. This commentary describes a model that uses a sociotechnical approach to guide implementation of improvement initiatives. The framework includes assessing whether systems are prepared for change, identifying leaders, and establishing goals.
Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-308.
Despite support for evidence-based medicine as a strategy to improve safety and quality, reliable use of best practices is lacking. Analyzing how six hospitals tried to implement evidence-based safety practices, this report identified in-house incident data use, practice selection, and implementation consistency as challenges to sustainable use of best practices.
Dixon-Woods M, Bosk CL, Aveling EL, et al. Milbank Q. 2011;89(2):167-205.
The remarkable success of the Keystone ICU project was initially publicized as an example of the power of checklists. While checklists are a useful safety tool, this study used an ethnographic approach to better understand the sociological factors that helped the project succeed. The authors highlight the densely networked community, the multimodal interventions, the data-driven processes, and the reframing of catheter-related blood stream infections as a social problem as important contextual factors that must be considered in quality improvement efforts. These lessons are especially important given that subsequent studies have found difficulty in implementing checklists in the absence of a robust safety culture.
Wrigstad J, Bergström J, Gustafson P. BMJ Open. 2014;4(5).
The effectiveness of root cause analysis (RCA) as a safety improvement tool has been called into question, as many institutions lack a formal mechanism for implementing and following up action items specified by RCAs. This Swedish study found that two factors predicted successful implementation of safety strategies after an RCA: management continuity and targeting corrective actions at the unit level (rather than at the organizational level).
Mello MM, Senecal SK, Kuznetsov Y, et al. Health Aff (Millwood). 2014;33(1):30-8.
This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.
Multi-use Website
Food and Drug Administration.
This Web site provides information related to the dangers of purchasing medical products online, including a link for consumers to report suspected illegal sites to the US Food and Drug Administration.
Pronovost P, Berenholtz SM, Goeschel CA, et al. J Crit Care. 2008;23(2):207-212.
The Keystone ICU project is a landmark achievement in patient safety. This project, funded by AHRQ, represented a collaboration between patient safety experts at Johns Hopkins University and the Michigan Hospital Association to improve patient safety in 99 intensive care units (ICUs). This article discusses implementation of the comprehensive unit-based safety program, which was the cornerstone of the project, and provides detailed information on the organizational change model used as well as the interventions that were implemented. The remarkable successes achieved by this project include near-elimination of catheter-related bloodstream infections and a significant improvement in the safety culture in participating ICUs. The project's principal investigator, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M near the project's conclusion in 2005.
Rogers G, Alper E, Brunelle D, et al. Jt Comm J Qual Patient Saf. 2016;32(1):37-50.
Medication reconciliation is a targeted National Patient Safety Goal. This study describes the experiences of 50 Massachusetts hospitals that collaborated in an initiative to implement a medication reconciliation process. The authors provide a summary of their safe practice recommendations and share their reconciliation form and accompanying instructions for use. They discuss the role and importance of leadership support, assembling a multidisciplinary team, maintaining a narrow focus to foster rapid changes to the process, and implementing the process into everyday workflow. Overall, the authors provide a practical, step-by-step experiential guide for institutions and individuals committed to the important medication reconciliation initiative.
Foy R, Ovretveit J, Shekelle PG, et al. BMJ Qual Saf. 2011;20(5):453-9.
The first decade of the patient safety movement has seen notable successes, but many highly publicized practices have been less impactful than anticipated. This AHRQ-funded expert panel calls for patient safety researchers to explicitly incorporate theories of individual behavior change and organizational improvement into the planning, implementation, and evaluation of patient safety research. Using established theoretical models has the potential to improve the odds of successful implementation of safety practices and increase the generalizability of successful strategies for other institutions. The importance of behavior change models in implementing checklists was discussed in a recent commentary, and Dr. Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change theories in an AHRQ WebM&M interview.
Burnett S, Benn J, Pinto A, et al. Qual Saf Health Care. 2010;19(4):313-7.
Implementation of large-scale safety improvement programs requires learning organizations—organizations with the capacity for change. The Safer Patients Initiative was implemented at four United Kingdom sites in 2004 in collaboration with the Institute for Healthcare Improvement with the goal of reducing preventable harm. This qualitative study evaluated the readiness of each organization to undertake this initiative, and found that a positive safety culture, a history of organizational leadership and involvement in safety initiatives, and availability of information technology for quality measurement were important predictors of successful implementation. The importance of strong organizational leadership in improving safety was recognized by The Joint Commission in a Sentinel Event Alert.
Commentary
Classic
Berwick D. New Engl J Med. 1989;320(1):53-56.
Two approaches to improving quality in health care are illustrated in this article. The first, called quality by inspection, is a system based on the belief that quality is best achieved by removing “bad apples.” The second, based on the theory of continuous improvement, calls for understanding and revision of the production process rather than placing blame on the individual. Berwick calls on the health care leaders to begin applying the continuous improvement model in medicine. He outlines a number of critical steps for implementation, including committing resources, organizing within institutions, using modern technical tools, encouraging dialogue between consumers and suppliers in the industry, and re-establishing trust in providers. He also calls for individual physicians to join in the movement, maintaining that these principles apply to individuals and small systems alike.
