Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 8
- Education and Training 6
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches 3
- Quality Improvement Strategies 9
- Teamwork 2
- Technologic Approaches 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 4
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Health Care Executives and Administrators 25
Health Care Providers
- Nurses 19
- Non-Health Care Professionals 7
Search results for "Book/Report"
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study.
Griffiths P, Ball J, Bloor K, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678.
The Crossing the Quality Chasm report provided a framework to improve quality and safety in health care. This publication draws on the six aims for quality outlined in the report to review core competencies, knowledge, and attitudes for safe nursing care. Topics covered include nurses as leaders, teamwork, and patient-centered care.
Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940446387.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 1-year period.
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277.
This publication provides information about the role of nurses in health care safety and explores how organizational dynamics, leadership, and hazard identification can affect the abilities of frontline nurses to deliver safe care. Helpful resources such as checklists, sample control plans, and review exercises are also included.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Charting Nursing's Future. Princeton, NJ: Robert Wood Johnson Foundation. Washington, DC: George Washington University School of Nursing. March 14, 2014;22:1-8.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; February 2014. Report No. OEI-06-11-00370.
This report from the Office of the Inspector General examines the nationwide incidence of adverse events in skilled nursing facilities among the Medicare population. Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event, and more than half were preventable. These results mirror previous studies documenting an overall poor level of safety culture in nursing homes. More than half of those who experienced harm were readmitted to the hospital. The report outlines recommendations, including raising awareness of safety concerns in this setting and instructing surveyors who inspect nursing homes to evaluate patient safety practices. These findings emphasize the importance of focusing outside acute care settings in order to advance patient safety by improving systems of care and by aligning accreditation and payment structures. A past AHRQ WebM&M interview discussed unique issues surrounding patient safety in the nursing home population.
Fisher MA, Scott M. London, UK: Sage Publishing; 2013. ISBN: 9781446266878.
Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.
This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.
Cima L, Clarke S, eds. Oakbrook Terrace, IL: Joint Commission; 2012. ISBN: 9781599406183.
Exploring nurses' role in care delivery and medication safety, this publication provides strategies for nurses to improve safety.
Sculli GL, Sine DM. Danvers, MA: HCPro, Inc; 2011. ISBN: 9781601467836.
This book describes how to apply aviation communication tactics to nursing practice.
Olson S. Committee on the Role of Human Factors in Home Healthcare, National Research Council. Washington, DC: National Academies Press; 2010.
This publication summarizes content from a 2009 AHRQ-funded workshop that explored the effect of behavior and human factors on home health care quality and safety.
Schuster PM, Nykolyn L. Philadelphia, PA: F.A. Davis Company; 2010. ISBN: 9780803620803.
This publication promotes fundamental communication skills to enable nurses to prevent errors and support patient safety.
Princeton, NJ: Robert Wood Johnson Foundation; November 2010.
Part I of this three-part series examines the quality improvement experience of four health care organizations and one state government. Part II examines how nursing intersects with health information technology implementation efforts. Part III examines how the design of the care environment affects patient outcomes.
Lindberg C, Nash S, Lindberg C. Bordentown, NJ: PlexusPress; 2008. ISBN: 1438246765.
This book provides a foundation on complexity science concepts and examines how they can be applied to effectively address challenges in nursing practice, research, and leadership.
Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
This handbook prepared by the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation provides a comprehensive summary of important patient safety and quality improvement concepts for frontline nurses. Experts in each topic area reviewed the latest published evidence to assemble sections on providing patient-centered care, nurses' working conditions and work environment, critical opportunities for improving quality and safety, and practical tools for implementing patient safety interventions for practicing nurses.