Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 4
- Education and Training 5
- Error Reporting and Analysis 1
- Human Factors Engineering 3
- Logistical Approaches 2
- Quality Improvement Strategies 8
- Teamwork 2
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 4
- Medication Safety 2
- Surgical Complications 2
Search results for "Health Care Providers"
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.
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.
Fisher MA, Scott M. London, UK: Sage Publishing; 2013. ISBN: 9781446266878.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
Chicago, IL: Health Research & Educational Trust; July 2013.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
This monograph provides guidance, tools, and techniques for hospitals to help decrease central line–associated bloodstream infections.
Edmondson AC, Schein EH. San Franscisco, CA: Jossey-Bass; 2012. ISBN: 9780787970932.
This book explores teamwork, including barriers to effective teamwork and tactics to enhance professional and organizational learning.
Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.
Silence Kills was a 2005 report that highlighted communication failures that contribute to patient harm. These included broken rules, poor teamwork, and disruptive behaviors. This report builds on those findings based on a survey of more than 6500 nurses and nurse managers. Key findings suggested that existing safety tools, such as checklists, are not in themselves solutions to these communication failures. Nurses identified dangerous shortcuts, incompetence, and disrespect as three concerns that undermine systems designed to provide safer care. A past AHRQ WebM&M perspective and interview discuss the role of checklists in health care settings.
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.
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.
Fitzpatrick J, Stone P, Hinton-Walker P, eds. Annual Review of Nursing Research. New York, NY: Springer; 2006. ISBN: 0826141366.
This volume includes research and reviews related to patient safety standards and practices in nursing.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
Newhouse R, Poe S, eds. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN: 0763728411.
This book provides nurses with the concepts and processes involved in improving patient safety. From discussion of safety principles to practical examples of project planning, the authors advocate for these important skills that give nurses the capacity to coordinate multidisciplinary safety efforts.
Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. VitalSmarts; 2005.E45
The American Association of Critical-Care Nurses (AACN) commissioned VitalSmarts to conduct a study exploring communication difficulties experienced by health care personnel that may contribute to medical error. Areas of concern include broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement.
McGillis Hall L, ed. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN: 0763728802.
This book summarizes findings from a literature review and analysis on factors that contribute to the quality of nursing work life. The authors present ten variables that impact work environments and their relation to patient safety.
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.