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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Technologic Approaches 2
- Fatigue and Sleep Deprivation 1
- Medical Complications 5
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Surgical Complications
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Cases & Commentaries
- Web M&M
Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
May H. Salt Lake Tribune. June 26, 2009.
Journal Article > Study
Bottle A, Aylin P. Qual Saf Health Care. 2009;18:303-308.
The Agency for Healthcare Research and Quality's Patient Safety Indicators were found to have limited utility in screening for patient safety problems in British hospitals.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Journal Article > Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Steelman VM, Cullen JJ. AORN J. 2011;94:132-141.