Implementing patient safety initiatives in rural hospitals.

Jill Klingner; Ira Moscovice; Judith B. Tupper; Andrew Coburn; Mary Wakefield

Commentary

Implementing patient safety initiatives in rural hospitals.

October 14, 2009

Klingner J, Moscovice I, Tupper JB, et al. The Journal of Rural Health. 2009;25(4).

View more articles from the same authors.

This commentary showcases a demonstration project that utilized the AHRQ Patient Safety Survey and other tools to support hospital partnerships with a variety of organizations to help implement and study patient safety improvement programs.

Available at

PubMed citation

Related Resources From the Same Author(s)

Prioritizing patient safety interventions in small and rural hospitals.

December 6, 2006

Pharmacist staffing, technology use, and implementation of medication safety practices in rural hospitals.

October 25, 2006

Little shop of errors: an innovative simulation patient safety workshop for community health care professionals.

May 29, 2013

The effect of health information technology on quality in U.S. hospitals.

April 28, 2010

Are verbal orders a threat to patient safety?

June 10, 2009

Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior.

January 30, 2008

Safety huddles in the PACU: when a patient self-medicates.

April 6, 2011

Simulation based adverse event reporting system: development and feasibility.

July 30, 2014

Participation in a system-thinking simulation experience changes adverse event reporting.

July 8, 2020

Patient safety culture: factors that influence clinician involvement in patient safety behaviours.

January 12, 2011

Evaluating the accuracy of electronic pediatric drug dosing rules.

April 23, 2014

Sleep deprivation: a call for institutional rules.

September 25, 2013

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

January 30, 2005

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

Workarounds in the workplace: a second look.

August 12, 2015

A 10-Rights framework for patient care quality and safety.

April 18, 2007

Work-arounds in health care settings: literature review and research agenda.

January 16, 2008

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

March 26, 2008

Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center.

January 16, 2013

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.

June 2, 2021

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

April 21, 2010

What causes near-misses and how are they mitigated?

June 5, 2013

Prescription of teratogenic medications in United States ambulatory practices.

January 4, 2006

Twitter as a tool to enhance student engagement during an interprofessional patient safety course.

May 21, 2014

Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort.

July 15, 2015

Educational targets to reduce medication errors by general surgery residents.

August 21, 2019

A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality.

October 20, 2021

Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing.

January 24, 2024

Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.

September 14, 2005

The impact of health information technology on the management and follow-up of test results—a systematic review.

May 8, 2019

Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic narrative review of the international literature.

June 2, 2021

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

November 3, 2010

A review of verbal order policies in acute care hospitals.

January 18, 2012

Preventing surgical site infections: are safety climate level and its strength associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures?

June 14, 2023

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

What COVID-19 teaches us about implicit bias in pediatric health care.

February 24, 2021

Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure.

January 28, 2015

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

December 22, 2010

Training in quality and safety: the current landscape.

August 27, 2014

Risk of misdiagnosis and delayed diagnosis with COVID-19: a syndemic approach.

February 10, 2021

Clinical deterioration and hospital‐acquired complications in adult patients with isolation precautions for infection control: a systematic review.

October 14, 2020

Healthcare staff wellbeing, burnout, and patient safety: a systematic review.

August 24, 2016

Assessing frequency and risk of weight entry errors in pediatrics.

February 15, 2017

Nurses: the patient's first—and perhaps last—line of defense.

June 24, 2009

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

It's always something: hospital nurses managing risk.

January 30, 2013

Making the transition to nursing bedside shift reports.

May 30, 2012

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

Validating patient safety in the endoscopy unit using The Joint Commission standards.

July 13, 2011

Five pitfalls in decisions about diagnosis and prescribing.

November 2, 2005

Emergency department visits for medical device–associated adverse events among children.

September 15, 2010

Practising open disclosure: clinical incident communication and systems improvement.

January 7, 2009

Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes.

June 20, 2018

12 h shifts and rates of error among nurses: a systematic review.

August 5, 2015

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

March 22, 2023

How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety?

December 7, 2022

Patient safety culture: the impact on workplace violence and health worker burnout.

February 8, 2023

Organizational climate determinants of resident safety culture in nursing homes.

July 20, 2011

Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis.

March 16, 2022

Conducting root cause analysis with nursing students: best practice in nursing education.

June 9, 2010

A case of mistaken identity: staff input on patient ID errors.

April 22, 2009

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

September 30, 2009

Nil per os orders for imaging: a teachable moment.

September 27, 2017

Patient mortality during unannounced accreditation surveys at US hospitals.

April 5, 2017

Opioid-prescribing patterns of emergency physicians and risk of long-term use.

March 1, 2017

A new structure of attention? Open disclosure of adverse events to patients and their families.

June 24, 2009

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

January 30, 2005

Relationship of staff information sharing and advice networks to patient safety outcomes.

January 30, 2019

Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes.

August 10, 2005

Information and power: women of color's experiences interacting with health care providers in pregnancy and birth.

August 12, 2019

Improving operating room safety.

December 16, 2009

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

March 9, 2011

Disposal of paper records containing personal information in hospitals.

March 28, 2018

Flying lessons for clinicians: developing system 2 practice.

June 21, 2017

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

September 22, 2010

Patient safety: do nursing and medical curricula address this theme?

June 1, 2005

Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.

March 23, 2016

Impact of an electronic health record transition on chemotherapy error reporting

October 16, 2019

Impact of an electronic health record transition on chemotherapy error reporting.

June 17, 2020

Association between treatment by locum tenens internal medicine physicians and 30-day mortality among hospitalized Medicare beneficiaries.

December 20, 2017

Review of the Australian Incident Monitoring System.

August 17, 2005

Improving hospital performance: culture change is not the answer.

May 4, 2005

Rapid response teams seen through the eyes of the nurse.

August 4, 2010

Sustained impact of a pediatric resident-led patient safety council.

August 1, 2018

Variation in medication information for elderly patients during initial interventions by emergency department physicians.

January 16, 2008

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records.

August 24, 2016

Impact of barcode medication administration technology on how nurses spend their time providing patient care.

January 7, 2009

Who applies an intervention to influence cultural attributes in a quality improvement collaborative?

September 16, 2015

Influence of the Comprehensive Unit-based Safety Program in ICUs: evidence from the Keystone ICU project.

March 18, 2015

Frontline nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: a qualitative study.

April 5, 2023

Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers.

July 8, 2020

Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.

June 22, 2011

Bar code technology and medication administration error.

June 9, 2010

Learning in action: developing safety improvement capabilities through action learning.

September 25, 2013

Implementing AORN recommended practices for prevention of retained surgical items.

February 15, 2012

Work-arounds observed by fourth-year nursing students.

November 19, 2014

Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting.

May 20, 2009

The views and experiences of patients and health-care professionals on the disclosure of adverse events: a systematic review and qualitative meta-ethnographic synthesis.

April 8, 2020

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Communication in critical care environments: mobile telephones improve patient care.

February 8, 2006

Related Resources

Hospital Reporting Program: Annual Summary.

December 27, 2023

Interview

In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Perspectives on Safety

Addressing Workplace Violence and Creating a Safer Workplace

October 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Preventing violence in the health care setting.

June 9, 2021

Combined SNA and LDA methods to understand adverse medical events

October 9, 2019

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

WebM&M Cases

Critical Order Set Change and Critical Limb Ischemia

January 1, 2019

Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative.

February 5, 2014

Patient safety: threats and solutions.

August 28, 2013

The role of technology in clinician-to-clinician communication.

August 14, 2013

Frontline hospital workers and the worker safety/patient safety nexus.

April 3, 2013

Inpatient fall prevention: use of in-room Webcams.

January 9, 2013

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

March 29, 2012

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study.

November 16, 2011

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

November 2, 2011

Creating a web-based incident analysis and communication system.

November 2, 2011

Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture.

October 19, 2011

Introducing the patient safety professional: why, what, who, how, and where?

September 28, 2011

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

July 20, 2011

Patient-assisted incident reporting: including the patient in patient safety.

June 1, 2011

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

May 4, 2011

Eliminating CLABSI: A National Patient Safety Imperative.

May 4, 2011

Perspective

The Second Victim Phenomenon: A Harsh Reality of Health Care Professions

May 1, 2011

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

April 27, 2011

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

April 13, 2011

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

March 30, 2011

See More About The Topic

General Hospitals

Health Care Providers

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Implementing patient safety initiatives in rural hospitals.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Implementing patient safety initiatives in rural hospitals.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site