Narrow Results Clear All
- Communication Improvement
- Culture of Safety 1
- Human Factors Engineering 1
- Legal and Policy Approaches 2
- Quality Improvement Strategies 3
- Teamwork 3
- Technologic Approaches 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 2
- Medication Safety 4
- Psychological and Social Complications 1
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Meeting/Conference > Government Resource
This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.
Journal Article > Study
A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.
Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.
Evaluating the impact of quality and safety interventions is an evolving science. While some have argued for a new paradigm in the field, others have advocated for standards similar to clinical trials. This study developed a comprehensive approach and model to increase prophylaxis against venous thromboembolic disease, ventilator-associated pneumonia, and stress ulcers in a single intensive care unit. The model included adoption of tools that promoted team communication, prompts to providers to address the evidence-based measures on a daily basis, and a data wall to provide real-time feedback. The authors provide a detailed description of their efforts that achieved near 100% target goals and advocate for this approach in creating successful microsystems that benefit from their refined Plan-Do-Study-Act methodology.
Journal Article > Review
Exploring the concept of medication discrepancy within the context of patient safety to improve population health.
Murphy CR, Corbett CL, Setter SM, Dupler A. ANS Adv Nurs Sci. 2009;32:338-350.
Drawing on the literature, this review defines medication discrepancy, identifies contributing factors, and explains how medication reconciliation can prevent it.
Journal Article > Commentary
Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.
This commentary discusses challenges for patient safety improvement work in the ambulatory setting along with recommendations for addressing them.
Journal Article > Review
Spinewine A, Claeys C, Foulon V, Chevalier P. Int J Qual Health Care. 2013;25:403-417.
This systematic review did not identify any clearly superior strategies of accomplishing medication reconciliation improvement at either hospital admission or hospital discharge.