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Implementation of Patient Safety Projects Curated Library

Last Updated: May 4, 2023
Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team

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 (8)

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

Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2023.

Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary... Read More

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All Library Content (22)
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Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.
Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.
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. This commentary provides a framework for choosing various interventions with a particular focus on what hospitalists should target for implementation. The authors advocate for a "balanced diet" approach in combining: (1) important practices with strong evidence (e.g., prevention of catheter-related blood stream infections), (2) momentum-generating projects (e.g., executive walk rounds), and (3) system-level interventions (e.g., computerized physician order entry [CPOE]). A previous AHRQ WebM&M perspective addresses how to interpret the patient safety literature.