Narrow Results Clear All
- Patient Safety Primers 9
- WebM&M Cases 167
Perspectives on Safety
- Interview 49
- Perspective 44
- Commentary 589
- Review 202
- Study 1031
- Slideset 6
- Book/Report 284
- Legislation/Regulation 95
- Newspaper/Magazine Article 289
- Newsletter/Journal 6
- Special or Theme Issue 87
- Toolkit 44
- Web Resource 265
- Award 14
- Bibliography 3
- Clinical Guideline 17
- Grant 9
- United States Meeting/Conference 4
- Upcoming Meeting/Conference 6
- Press Release/Announcement 36
Communication between Providers
- Sbar 3
- Communication between Providers 267
- Culture of Safety 435
Education and Training
- Simulators 25
- Students 16
Error Reporting and Analysis
- Error Analysis 272
- Error Reporting 262
Human Factors Engineering
- Checklists 99
Legal and Policy Approaches
- Regulation 54
- Logistical Approaches 82
- Policies and Operations 11
Quality Improvement Strategies
- Benchmarking 258
- Reminders 77
- Six Sigma 23
- Research Directions 28
- Specialization of Care 109
- Teamwork 170
- Clinical Information Systems 179
- Transparency and Accountability 10
- Alert fatigue 6
- Device-related Complications 166
- Diagnostic Errors 215
- Discontinuities, Gaps, and Hand-Off Problems 233
- Drug shortages 10
- Failure to rescue 3
- Fatigue and Sleep Deprivation 25
- Identification Errors 77
- Inpatient suicide 3
- Interruptions and distractions 19
- Delirium 9
- Medication Errors/Preventable Adverse Drug Events 495
- MRI safety 10
- Nonsurgical Procedural Complications 100
- Overtreatment 11
- Psychological and Social Complications 90
- Second victims 5
- Surgical Complications 320
- Transfusion Complications 13
- Home Care 23
- Operating Room 241
- General Hospitals 662
- Long-Term Care 56
- Outpatient Surgery 39
- Patient Transport 15
- Psychiatric Facilities 13
- Allied Health Services 13
- Dentistry 4
- Critical Care 159
- Dermatology 10
- Gynecology 75
- Cardiology 36
- Geriatrics 81
- Hematology 16
- Nephrology 11
- Pulmonology 17
- Neurology 25
- Obstetrics 91
- Pediatrics 188
- Primary Care 103
- Radiology 68
- Nursing 211
- Palliative Care 7
- Pharmacy 226
- Family Members and Caregivers 34
Health Care Executives and Administrators
- Nurse Managers 171
- Risk Managers 252
Health Care Providers
- Nurses 323
- Pharmacists 144
- Physicians 465
Non-Health Care Professionals
- Educators 148
- Engineers 35
- Media 14
- Policy Makers 245
- Patients 191
- Africa 8
- China 7
- Australia and New Zealand 83
- Central and South America 7
- United Kingdom 299
- Canada 114
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 194
- United States Federal Government 261
Search results for "Quality Improvement Strategies"
- Quality Improvement Strategies
Meeting/Conference > Maryland Meeting/Conference
Johns Hopkins Medicine, Armstrong Institute for Patient Safety. November 18-20, 2019; Constellation Energy Building, Baltimore, MD.
Meeting/Conference > California Meeting/Conference
Hospital Quality Institute. October 14-15, 2019. Golden 1 Center, Sacramento, CA.
Meeting/Conference > Ohio Meeting/Conference
American College of Healthcare Executives. October 10–11, 2019; Cleveland Clinic, Cleveland, OH.
Leadership engagement has an important role in generating sustained improvements. This workshop for hospital executives and clinical administrators will provide experiential learning and peer engagement opportunities to help leaders engage their staff in building a culture that supports safety improvement.
Meeting/Conference > Asia Meeting/Conference
British Medical Journal, Institute for Healthcare Improvement. September 18–20, 2019; Taipei City, Taiwan.
This program will explore health care quality and safety and focus on the theme "Transforming Quality for Tomorrow." Topics covered will include enhancing patient- and family-centered care, promoting joy in practice, and building leadership capacity. Featured speakers include Dr. Donald Berwick and Derek Feeley.
Meeting/Conference > Canada Meeting/Conference
Canadian Patient Safety Institute. September 12, 2019; 12:00–1:00 PM (Eastern).
Structured approaches to manage negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar is part of a series of discussions on peer support efforts for Canadian health care workers.
Meeting/Conference > United States Meeting/Conference
Institute for Healthcare Improvement. September 2019–February 2020.
Maternal harm in the United States is gaining increased attention as a patient safety concern. This collaborative network will help build participants' skills to implement best practices and improve care delivery for women and newborns. A recent WebM&M commentary discussed an incident involving maternal harm.
Special or Theme Issue
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
Perspectives on Safety > Interview
Patient Safety at 20, September 2019
Dr. Agrawal is president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.
Perspectives on Safety > Perspective
with commentary by Sumant Ranji, MD, and Robert M. Wachter, MD, Patient Safety at 20, September 2019
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
Cases & Commentaries
- Web M&M
Zara Cooper, MD, MSc; September 2019
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.
Journal Article > Study
Mirarchi FL, Juhasz K, Cooney TE, et al. J Patient Saf. 2019;15:230-237.
This single-center study found that Do-Not-Resuscitate (DNR) orders and Physician Orders for Life-Sustaining Treatment (POLSTs) created at hospital admission often do not reflect the true wishes of patients and their caregivers. When queried by study staff, 44% of patients expressed wishes for life-sustaining treatment that differed from their designated code status; this resulted in revocation of the DNR order in more than one-third of patients with a discrepancy. A prior study argued that inaccurate documentation of patient's wishes for end-of-life care should be considered a medical error.
ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
Mistakes in the administration of intravenous (IV) medications can result in patient harm. Analyzing data from 243 health care facilities regarding the quality of IV push practices in the field, this newsletter article reports adoption of practices such as the use of a new syringe and needle for every IV push injection and outlines 10 best practices to consider for improvement, including the routine supply of IV push medications in ready-to-administer containers and reporting to external bodies to enhance learning.
Journal Article > Study
Woodcock T, Liberati EG, Dixon-Woods M. BMJ Qual Saf. 2019 Aug 24; [Epub ahead of print].
The development of accurate and reliable measurements was identified as a major priority for the patient safety field in an influential 2015 report. This mixed-methods study of a large-scale improvement program in the United Kingdom provides important insights into the challenges of measuring safety in real-world settings. In the program, quality improvement teams at each of the nine participating hospitals chose targets and developed metrics with assistance from external mentors. The measurement strategies were reviewed by the study investigators, who also conducted structured interviews with quality improvement team members at each site. Measurement was a challenge for all sites, attributed in large part to frontline staff's lack of experience in data analysis and reliance on homegrown rather than externally validated safety metrics. This manifested in the use of metrics that often were overambitious, not linked to the interventions that were being implemented, or not analyzed in a statistically appropriate fashion. As a result, it was difficult to determine if improvement in the safety targets had been achieved. A previous PSNet interview featured the study's senior author, Mary Dixon-Woods.
R3 Report. August 21, 2019;24:1-6.
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.
National Quality Forum.
Journal Article > Commentary
Chidgey BA, McGinigle KL, McNaull PP. JAMA Surg. 2019 Aug 14; [Epub ahead of print].
This commentary discusses how regulation, misinformation, and cultural beliefs influenced opioid prescribing behaviors for pain management that contributed to the opioid crisis. The author reviews efforts to address the problem, including a comprehensive approach to promote the use of nonopioid analgesics in perioperative care.
Journal Article > Study
Dinsdale E, Hannigan A, O'Connor R, et al. Fam Pract. 2019 Aug 2; [Epub ahead of print].
Clear communication between primary care physicians and the providers to whom they refer patients has important implications for achieving accurate diagnosis and appropriate treatment plans for patients. In this observational study, researchers included 6603 patients from 68 general medical practices in Ireland, randomly selecting 100 patients from each practice and excluding patients without complete records. They analyzed referral documentation and responses received from subspecialists as well as discharge summaries from hospitalizations over a 2-year period, compared with established national standards. Although 82% of referral letters included current medications, only 30% of response letters and discharge summaries contained medication changes and 33% had medication lists. The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them. A past PSNet perspective discussed challenges associated with care transitions.
Cases & Commentaries
- Spotlight Case
- Web M&M
Mythili P. Pathipati, MD, and James M. Richter, MD; August 2019
An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.
Cases & Commentaries
- Web M&M
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.