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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering
- Legal and Policy Approaches 2
- Quality Improvement Strategies
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 3
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Journal Article > Study
Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.
Armbruster DA, Alexander DB. Clin Chim Acta. 2006;373:37-43.
The investigators present a protocol to measure and assess specimen-to-specimen contamination in large sets of laboratory samples using an integrated system.
Meeting/Conference > Government Resource
This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.
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.
Journal Article > Study
Adherence to Surgical Care Improvement Project measures and the association with postoperative infections.
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. JAMA. 2010;303:2479-2485.
Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.
Journal Article > Commentary
Mellin-Olsen J, Staender S. Curr Opin Anaesthesiol. 2014;27:630-634.