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- WebM&M Cases 6
- Perspectives on Safety 2
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- Slideset 1
- Book/Report 32
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- Newspaper/Magazine Article 92
- Special or Theme Issue 2
- Toolkit 4
- Web Resource 33
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- Culture of Safety 17
- Education and Training 34
Error Reporting and Analysis
- Error Reporting 35
- Human Factors Engineering 19
- Legal and Policy Approaches 46
- Logistical Approaches 7
Quality Improvement Strategies
- Benchmarking 21
- Research Directions 2
- Specialization of Care 6
- Teamwork 5
- Technologic Approaches 18
- Transparency and Accountability 3
- Device-related Complications 9
- Diagnostic Errors 19
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 1
- Identification Errors 11
- Medical Complications 28
- Medication Errors/Preventable Adverse Drug Events 29
- MRI safety 1
- Nonsurgical Procedural Complications 5
- Overtreatment 2
- Psychological and Social Complications 6
- Surgical Complications 25
- Transfusion Complications 2
- Ambulatory Care 17
- General Hospitals 32
- Long-Term Care 2
- Outpatient Surgery 4
- Patient Transport 1
- Internal Medicine 50
- Nursing 7
- Palliative Care 1
- Pharmacy 18
- Family Members and Caregivers 13
- Health Care Executives and Administrators 91
Health Care Providers
- Nurses 12
- Physicians 18
Non-Health Care Professionals
- Media 7
- Europe 15
- Canada 5
Search results for "Quality Improvement Strategies"
- Quality Improvement Strategies
National Quality Forum.
Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.
The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
Bornstein D. New York Times. January 26, and February 2, 2016.
Discussing the importance of designing safeguards to prevent system failures that can result in patient harm, this two-part newspaper article reviews large-scale collaboratives, including the Partnership for Patients initiative, as approaches that show promise in engaging clinicians in safety improvement and explores specific areas of focus to reduce harm such as hospital-acquired infections, patient falls, and culture change.
Shell ER. Sci Am. 2015;313(5):28-29.
Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?
Gawande A. New Yorker. May 11, 2015.
The overuse of medical care and its negative impact on personal health and finances is an emerging concern. This magazine article provides insights from a surgeon about how providing unnecessary care can contribute to patient harm and waste. Consequences of unneeded medical care include overtesting, overdiagnosis, and overtreatment. A previous AHRQ WebM&M perspective explored overuse as a patient safety problem.
Webb J. Drug Topics. March 10, 2015.
Pharmacies can serve as gatekeepers to ensure patients receive the correct medications. A 10-year study of claims data found that the majority of claims were related to wrong dose and wrong drug dispensing errors. This news article discusses injuries that resulted from the errors and provides recommendations to augment safety, including the design and use of order review and quality control systems to reduce the risk of human error in pharmacy services.
Landro L. Wall Street Journal. February 16, 2015.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
This Web site features resources to support the Medicare Quality Improvement Program and Medicare Quality Improvement Organizations (QIOs) in delivering quality care.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Rusk K. Assignment 7. ABC7news.com. May 26, 2008.
In the context of statewide efforts to prevent medication errors, increase reporting, and share best practices, this news video addresses how hospitals are employing both low- and high-tech solutions to improve patient safety. The story also covers barcoding, the Five Rights, transparency, and efforts to get safety information into patients' hands.
Carruthers I, Phillip P. London, UK: National Patient Safety Agency; 2006.
This report reviews the challenges of patient safety efforts of the National Health Service and provides recommendations to further improve health care safety.
Landro L. Wall Street Journal (Eastern Edition). November 1, 2006:D1. [reprinted on Post-gazette.com].
This article reports on the updated set of safe practices to be released by the National Quality Forum.
P-I Staff and News Services. Seattle Post-Intelligencer. June 15, 2006:A1.
This article article reports on the results of the the 100,000 Lives Campaign.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Szabo L. USA Today. August 23, 2005.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Web Resource > Multi-use Website
2410A Hyde Park Road, Jefferson City, MO 65109.
The Missouri Center for Patient Safety is dedicated to improving patient safety in Missouri by applying evidence-based methods and best practices. The private, not-for-profit corporation was established by the Missouri State Medical Association, the Missouri Hospital Association, and Primaris, a quality improvement organization.
Berwick DM. New York, NY: The Commonwealth Fund; 2002.
This report represents an edited version of Donald Berwick's Plenary Address presented at the Institute for Healthcare Improvement's 11th Annual National Forum on Quality Improvement in Health Care (December 1999). In his address to more than 3000 attendees, Berwick uses the story of the Mann Gulch Fire tragedy to frame a series of reflections on the failures of systems, organizations, and individuals who operate within them. He goes on to share his personal experience with the health care system in describing the details of his wife's illness that required several hospitalizations, placing him at the sharp end to experience our system's shortcomings on a daily basis. He builds on the anecdotes by describing factors that contribute to an organization's failures, once again incorporating a number of analogies that make his delivery of content easy to grasp for novices and experts in the audience. Finally, Berwick proposes three design elements in creating a radically different and much improved health care system. They include greater access for patients to the system, improved application of science at the bedside, and better attention to the interactions between patients and the system.
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.