Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety
- Education and Training 2
- Error Reporting and Analysis 4
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 1
- Device-related Complications 3
- Medical Complications
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Surgical Complications 6
Search results for ""
Cases & Commentaries
- Web M&M
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
Web Resource > Multi-use Website
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Journal Article > Commentary
Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.
Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.
This case study discusses errors that contributed to transplantation of infected organs and provides recommendations to improve test result communication and organizational safety culture.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Journal Article > Study
Chang BH, Hsu YJ, Rosen MA, et al. Am J Med Qual. 2019 May 3; [Epub ahead of print].
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.