Improving Quality and Safety in Healthcare.

Special or Theme Issue

Improving Quality and Safety in Healthcare.

October 26, 2022

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 strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.

Free full text

Related Resources From the Same Author(s)

Safer Clinical Systems: Evaluation Findings.

February 18, 2015

Human Error.

March 27, 2005

Merry and McCall Smith's Errors, Medicine, and the Law. 2nd ed.

March 6, 2005

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

May 23, 2018

Judgment under Uncertainty: Heuristics and Biases.

March 6, 2005

Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature.

May 30, 2012

A qualitative study of speaking out about patient safety concerns in intensive care units.

October 25, 2017

Explaining Matching Michigan: an ethnographic study of a patient safety program.

August 21, 2013

An ethnographic study of classifying and accounting for risk at the sharp end of medical wards.

July 15, 2009

How will it work? A qualitative study of strategic stakeholders' accounts of a patient safety initiative.

March 10, 2010

Improving employee voice about transgressive or disruptive behavior: a case study.

April 17, 2019

What to expect when you're evaluating healthcare improvement: a concordat approach to managing collaboration and uncomfortable realities.

April 29, 2015

How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals.

March 13, 2019

How well is quality improvement described in the perioperative care literature? A systematic review.

May 4, 2016

A decade after Francis: is the NHS safer and more open?

April 5, 2023

The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation.

September 24, 2014

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.

March 14, 2018

After Mid Staffordshire: from acknowledgement, through learning, to improvement.

August 27, 2014

How to be a very safe maternity unit: an ethnographic study.

February 20, 2019

Walkrounds in practice: corrupting or enhancing a quality improvement intervention? A qualitative study.

July 2, 2014

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.

April 10, 2019

What methods are used to apply positive deviance within healthcare organisations? A systematic review.

March 2, 2016

Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer.

August 1, 2018

Harveian Oration 2018: improving quality and safety in healthcare.

February 13, 2019

Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.

March 27, 2005

Between surveillance and subjectification: professionals and the governance of quality and patient safety in English hospitals.

March 5, 2014

Estimating deaths due to medical error: the ongoing controversy and why it matters.

October 26, 2016

'Bad apples': time to redefine as a type of systems problem?

June 26, 2013

Oxford Professional Practice: Handbook of Patient Safety.

July 27, 2022

Patient safety and the problem of many hands.

March 30, 2016

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.

January 31, 2018

A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries.

September 4, 2013

What is the role of individual accountability in patient safety? A multi-site ethnographic study.

November 25, 2015

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.

October 16, 2013

Doctors' experiences of adverse events in secondary care: the professional and personal impact.

February 11, 2015

Families’ experiences of central-line infection in children: a qualitative study.

September 7, 2022

Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff?

September 29, 2021

The problem with root cause analysis.

July 13, 2016

Changing the narratives for patient safety.

June 28, 2017

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

October 21, 2015

Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.

October 23, 2013

Running a hospital patient safety campaign: a qualitative study.

September 17, 2014

Reality check for checklists.

August 19, 2009

Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being.

July 14, 2010

Improving Patient Safety Through Teamwork and Team Training.

January 29, 2014

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.

December 5, 2018

How to master the new art of training: teamwork on the fly.

April 11, 2012

Strategies for learning from failure.

April 6, 2011

The competitive imperative of learning.

August 20, 2008

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.

March 6, 2005

Explaining Michigan: developing an ex post theory of a quality improvement program.

August 3, 2011

What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.

January 19, 2022

Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy.

May 16, 2012

Organizational learning: health care leaders need to design structures and processes that enhance collective learning.

March 27, 2005

Using clinical simulation to study how to improve quality and safety in healthcare.

September 29, 2018

Medical Problem Solving: An Analysis of Clinical Reasoning.

March 27, 2005

Emotion and coping in the aftermath of medical error: a cross-country exploration.

March 4, 2015

Is yours a learning organization?

March 12, 2008

Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.

June 22, 2022

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

What's the difference between a hospital and a bottling factory?

August 5, 2009

Measuring teamwork in health care settings: a review of survey instruments.

July 1, 2015

Facing ambiguous threats.

December 13, 2006

The role of the informal and formal organisation in voice about concerns in healthcare: a qualitative interview study.

June 16, 2021

Resilience Engineering in Practice: a Guidebook.

January 12, 2011

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Understanding psychological safety in health care and education organizations: a comparative perspective.

March 16, 2016

A mixed-methods study of challenges experienced by clinical teams in measuring improvement.

September 11, 2019

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.

May 9, 2018

Organizing for Reliability: A Guide for Research and Practice.

January 30, 2019

Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.

February 17, 2016

Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach.

November 2, 2016

Practical Patient Safety.

October 14, 2009

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

February 23, 2023

Positive deviance: a different approach to achieving patient safety.

August 20, 2014

Quality and Safety in Anesthesia and Perioperative Care.

July 17, 2019

'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas.

February 27, 2008

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

September 25, 2013

WebM&M Cases

Root Cause Analysis Gone Wrong

May 1, 2018

"No-go considerations" for in situ simulation safety.

June 13, 2018

Unity of Mistakes: A Phenomenological Interpretation of Medical Work.

March 6, 2005

Making infection prevention and control everyone's business? Hospital staff views on patient involvement.

June 5, 2019

Normal Accidents: Living with High-Risk Technologies.

March 6, 2005

Addressing the Opioid Crisis in the United States.

November 2, 2016

The next phase of health care improvement: what can we learn from social movements?

March 6, 2005

The Limits of Safety: Organizations, Accidents and Nuclear Weapons.

March 6, 2005

Junior doctors' views on reporting concerns about patient safety: a qualitative study.

June 17, 2015

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

January 27, 2021

Error and Uncertainty in Diagnostic Radiology.

March 20, 2019

Patient Safety Ethics: How Vigilance, Mindfulness, Compliance, and Humility can Make Healthcare Safer.

July 24, 2019

Are Workarounds Ethical? Managing Moral Problems in Health Care Systems.

February 3, 2016

Patient Safety: Research into Practice.

September 13, 2006

Accountability: Patient Safety and Policy Reform.

March 6, 2005

Behind Human Error, Second Edition.

November 10, 2017

National Plan for Health Workforce Well-Being.

September 28, 2022

After Harm: Medical Error and the Ethics of Forgiveness.

September 14, 2005

Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations

January 22, 2020

Still Not Safe: Patient Safety and the Middle-Managing of American Medicine.

December 18, 2019

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.

June 6, 2012

Listening for What Matters: Avoiding Contextual Errors in Health Care.

March 9, 2016

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Tools for establishing a sustainable safety culture within maternity services: a retrospective case study.

April 26, 2023

Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact.

April 19, 2023

STAMP: a 5-year project to reduce paediatric prescribing errors.

April 19, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

A high-reliability organization mindset.

February 22, 2023

Interventions to increase patient safety in long-term care facilities-umbrella review.

January 25, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Designing safety interventions for specific contexts: results from a literature review.

October 26, 2022

HSIB Education.

October 19, 2022

Experience of learning from everyday work in daily safety huddles: a multi-method study.

September 14, 2022

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 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

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Development and validation of a brief culture-of-safety survey.

June 22, 2022

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

June 8, 2022

Quality Special Issue.

April 13, 2022

Human Factors In Healthcare.

March 23, 2022

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Evaluating incident learning systems and safety culture in two radiation oncology departments.

February 16, 2022

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

August 18, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

March 3, 2021

The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis.

February 3, 2021

High-Performance Work Systems in Health Care Management: Parts 1-5.

October 4, 2020

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Safety Scientists

Epidemiology of Errors and Adverse Events

Latent Errors

Improving Quality and Safety in Healthcare.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving Quality and Safety in Healthcare.

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