Engaging the front line: tapping into hospital-wide quality and safety initiatives.

Jed Wolpaw; Deborah Schwengel; Nadia Hensley; Bommy Hong Mershon; Tracey Stierer; Anne Steele; Alexandra Hansen; Colleen G Koch

Commentary

Engaging the front line: tapping into hospital-wide quality and safety initiatives.

March 14, 2018

Wolpaw J, Schwengel D, Hensley N, et al. J Cardiothorac Vasc Anesth. 2018;32(1):522-533.

View more articles from the same authors.

Engaging clinicians and hospital staff is important for sustainable quality and safety improvement. This commentary describes a program to enhance staff involvement by providing education in risk identification, process assessment, project management, and patient engagement.

PubMed citation

Available at

Related Resources From the Same Author(s)

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences.

March 29, 2017

Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program.

October 30, 2013

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

September 13, 2006

A novel approach to implementation of quality and safety programmes in anaesthesiology.

December 7, 2011

Implementation and outcomes of a rapid response team.

October 3, 2007

A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient safety.

May 28, 2008

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

January 25, 2006

Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.

April 4, 2007

Case study research: the view from complexity science.

May 4, 2005

Clinical clerkship students' perceptions of (un)safe transitions for every patient.

May 14, 2014

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care.

January 6, 2016

North Mississippi Medical Center: a focus on quality, safety, and financial critical success factors.

October 12, 2005

Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?

October 22, 2014

How hospital leaders contribute to patient safety through the development of trust.

February 19, 2014

Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.

April 27, 2022

The effect of automated alerts on provider ordering behavior in an outpatient setting.

September 21, 2005

Medication errors in community pharmacies: the need for commitment, transparency, and research.

February 20, 2019

Structured patient handoff on an internal medicine ward: a cluster randomized control trial.

July 25, 2018

A model for the departmental quality management infrastructure within an academic health system.

September 28, 2016

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

April 11, 2012

Underdiagnosis of hypertension in children and adolescents.

September 5, 2007

Perceptions of hospital safety climate and incidence of readmission.

December 15, 2010

Serious adverse drug events reported to the FDA: analysis of the FDA Adverse Event Reporting System 2006–2014 database.

October 17, 2018

Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project.

March 21, 2018

Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial.

February 7, 2018

Correlation between hospital finances and quality and safety of patient care.

September 4, 2019

Failure mode and effects analysis application to critical care medicine.

April 21, 2005

Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety.

February 7, 2007

Training operating room teams in damage control surgery for trauma: a followup study of the Norwegian model.

November 14, 2007

Medication administration and interruptions in nursing homes: a qualitative observational study.

July 11, 2018

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

November 25, 2020

A multidisciplinary team approach to retained foreign objects.

March 4, 2009

In situ simulation: a method of experiential learning to promote safety and team behavior.

June 4, 2008

Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses.

February 15, 2006

Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities.

September 7, 2022

Safety events in pediatric out-of-hospital cardiac arrest.

September 13, 2017

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

January 30, 2005

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

August 7, 2013

Implementation of a medication reconciliation process in an ambulatory internal medicine clinic.

April 18, 2007

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

Online medication error graphic reports: a pilot in North Carolina nursing homes.

June 15, 2011

Emergency medical services provider pediatric adverse event rate varies by call origin pediatric emergency care.

August 3, 2016

Fatigue in nurses and medication administration errors: a scoping review.

March 8, 2023

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

August 10, 2011

Evaluating sample medications in primary care: a practice-based research network study.

December 6, 2006

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

December 15, 2010

Economic impact of medication error: a systematic review.

May 17, 2017

Data collection for adverse events reporting by US dental schools.

September 30, 2020

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Medical error and decision making: learning from the past and present in intensive care.

July 21, 2010

Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative.

February 8, 2006

Health care worker fatigue.

September 21, 2016

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis.

June 17, 2020

Near-miss medication errors provide a wake-up call.

February 7, 2018

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.

August 29, 2007

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

July 28, 2010

Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS.

November 23, 2016

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

March 22, 2017

Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study).

February 3, 2016

Dissemination of Lean methods to improve Pap testing quality and patient safety.

April 8, 2008

Do drug interaction alerts between a chemotherapy order-entry system and an electronic medical record affect clinician behavior?

July 17, 2013

ASHP guidelines on perioperative pharmacy services.

August 28, 2019

Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs.

February 6, 2013

Medication reconciliation in ambulatory care: attempts at improvement.

October 28, 2009

A review of organizational culture instruments for nurse executives.

February 21, 2007

Emerging issues and challenges for improving patient safety in mental health: a qualitative analysis of expert perspectives.

March 2, 2011

Out-of-hospital pediatric patient safety events: results of the CSI chart review.

November 15, 2017

Measuring harm in health care: optimizing adverse event review.

May 3, 2017

Patient safety perceptions in pediatric out-of-hospital emergency care: Children's Safety Initiative.

September 9, 2015

Preventing retained surgical items.

August 3, 2022

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries.

March 27, 2013

Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident.

October 6, 2021

Hospital discharge documentation and risk of rehospitalisation.

May 4, 2011

Transforming the health care environment collaborative.

April 9, 2014

Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals.

October 8, 2014

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

August 21, 2013

Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic.

March 28, 2007

The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support.

June 16, 2010

Nursing surveillance: a concept analysis

May 18, 2022

Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study.

September 23, 2020

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial.

May 23, 2012

Nurses' role in medication safety.

November 3, 2010

The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.

December 21, 2016

The impact of computerized provider order entry on medication errors in a multispecialty group practice.

February 3, 2010

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

Parent perceptions of children's hospital safety climate.

April 17, 2013

Patient perceptions of deterioration and patient and family activated escalation systems—a qualitative study.

April 4, 2018

Pediatric airway management and prehospital patient safety: results of a national Delphi survey by the Children's Safety Initiative-Emergency Medical Services for Children.

August 17, 2016

Project BOOST implementation: lessons learned.

September 10, 2014

Characterization of prescribing errors in an internal medicine clinic.

May 23, 2007

Activation of a medical emergency team using an electronic medical recording–based screening system.

June 18, 2014

Adverse events associated with home blood transfusion: a retrospective cohort study.

May 12, 2021

Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial.

May 2, 2018

Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety.

October 5, 2016

Using root cause analysis to reduce falls with injury in community settings.

August 1, 2012

Using root cause analysis to reduce falls with injury in the psychiatric unit.

March 21, 2012

An innovative tool for experiential learning of nursing quality and safety competencies.

May 8, 2013

How is safety climate measured? A review and evaluation.

October 20, 2021

Related Resources

Certified Professional in Patient Safety Review Course.

August 2, 2023 - August 3, 2023

The time is now: addressing implicit bias in obstetrics and gynecology education.

May 17, 2023

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

May 10, 2023

Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Using a learning system approach to improve safety for prone-position ventilation patients.

April 26, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

March 1, 2023

National patient safety goal to improve health care equity.

February 8, 2023

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

February 1, 2023

Rise to Health Coalition.

December 14, 2022

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

Journal Article

Commentary

Critical care resource nurse team: a patient safety and quality outcomes model.

November 16, 2022

Journal Article

Study

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

November 16, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

HSIB Education.

October 19, 2022

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

Advancing Anticoagulation Stewardship: A Playbook.

September 7, 2022

Physicians and cognitive decline: a challenge for state medical boards.

September 7, 2022

Patient safety: where to aim when zero harm is not the target-a case for learning and resilience.

August 31, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

How cisgender clinicians can help prevent harm during encounters with transgender patients.

August 24, 2022

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.

August 10, 2022

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019.

August 3, 2022

Development of a multicomponent intervention to decrease racial bias among healthcare staff.

July 27, 2022

Reducing pediatric emergency department prescription errors.

June 22, 2022

See More About The Topic

Hospitals

Facility and Group Administrators

Medicine

Epidemiology of Errors and Adverse Events

Continuous Quality Improvement

Engaging the front line: tapping into hospital-wide quality and safety initiatives.

Critical care resource nurse team: a patient safety and quality outcomes model.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Engaging the front line: tapping into hospital-wide quality and safety initiatives.

Critical care resource nurse team: a patient safety and quality outcomes model.

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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