Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Education and Training"

1 - 20 of 314 results
Download Selected Citations

Show: 20 | 50 | 100

Special or Theme Issue

Quality, Value, and Patient Safety in Orthopedic Surgery.

Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.

Book/Report

Toolkit to Promote Safe Surgery.

Rockville, MD: Agency for Healthcare Research and Quality; November 2017.

Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.

Journal Article > Commentary

Remembering to learn: the overlooked role of remembrance in safety improvement.

Macrae C. BMJ Qual Saf. 2017;26:678-682.

A key activity in patient safety work involves drawing from institutional memory to understand failures and design interventions to prevent them from reoccurring. This commentary discusses learning from failure, or remembrance, in health care and suggests avenues for future research to increase its application in improvement efforts.

Bibliography

Annotated bibliography: understanding ambulatory care practices in the context of patient safety and quality improvement.

Montano MF, Mehdi H, Nash DB. Am J Med Qual. 2016;31(suppl 2):29S-43S.

The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.

Journal Article > Study

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

Soban LM, Kim L, Yuan AH, Miltner RS. J Nurs Manag. 2017;25:457-467.

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

Legislation/Regulation > Organizational Policy/Guidelines

Safe injection, infusion, and medication vial practices in health care (2016).

Dolan SA, Arias KM, Felizardo G, et al. Washington, DC: Association for Professionals in Infection Control and Epidemiology; February 2016.

Improper injection practices associated with point-of-care testing and treatment can contribute to the spread of health care–associated infections. This position paper outlines how clinicians and infection preventionists can reduce unsafe behaviors with surveillance, oversight, enforcement, individual skills development, and professional accountability.

Journal Article > Study

Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

  • Classic

Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2016 Jan 7; [Epub ahead of print].

A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.

Journal Article > Commentary

Introduction to the STS National Database Series: outcomes analysis, quality improvement, and patient safety.

Jacobs JP, Shahian DM, Prager RL, et al. Ann Thorac Surg. 2015;100:1992-2000.

Enabling clinicians and management to access data can help them uncover weaknesses in practice, determine performance measures, and drive improvements. This commentary introduces a series of upcoming articles that will explore information derived from the Society of Thoracic Surgeons National Database to aid in understanding patient safety hazards in cardiothoracic surgery.

Book/Report

The Habits of an Improver. Thinking About Learning for Improvement in Health Care.

Lucas B, Nacer H. London, UK: Health Foundation; October 2015. ISBN: 9781906461676.

Committed leadership is essential to enhance organizational safety. Drawing from previous recommendations to generate lasting improvements in response to the Francis inquiry, this report discusses a model that focuses on learning, influencing, resilience, creativity, and systems thinking to help clinicians frame discussions about improving quality and safety in health care.

Book/Report

Guidelines for Adult IV Push Medications.

Horsham, PA: The Institute for Safe Medication Practices; July 2015.

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

Journal Article > Commentary

A collaborative learning network approach to improvement: the CUSP learning network.

Weaver SJ, Lofthus J, Sawyer M, et al. Jt Comm J Qual Patient Saf. 2015;41:147-159.

The comprehensive unit-based safety program (CUSP), originally developed by Dr. Peter Pronovost and others at Johns Hopkins, has been shown to improve safety culture in multiple clinical settings. This commentary describes the development of a quality improvement collaborative designed to facilitate the implementation of CUSP in a group of academic and community hospitals. In addition to discussing the mentorship and network learning aspects of the collaborative, the authors also provide detailed descriptions of the implementation process and barriers faced at each institution. A prior article explored the role of quality improvement collaboratives in enhancing safety. Dr. Pronovost talked about his work with checklists and the science of improving patient safety in a past AHRQ WebM&M interview.

Newspaper/Magazine Article

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.

Book/Report

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2018.

This report summarizes progress in patient safety improvement in the past decade and reviews the 2017 activities of the Patient Safety Authority, including an update on efforts to standardize their reporting processes and to reduce health care–associated infections in nursing homes. The report also summarizes the new 5-year strategic plan for the agency that explicitly emphasizes a focus on improving diagnosis.

Perspectives on Safety > Interview

In Conversation with...Brent C. James, MD, MStat

Educating Practitioners in Safety and Quality, February 2011

Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare.

Cases & Commentaries

One Toxic Drug Is Not Like Another

  • Spotlight Case
  • Web M&M

Eric S. Holmboe, MD; February 2011

A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.

Perspectives on Safety > Perspective

The University of Texas System Clinical Safety and Effectiveness Course

with commentary by Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD, Educating Practitioners in Safety and Quality, February 2011

Health care in the United States is undergoing profound changes due to societal demands to improve the quality of care and simultaneously reduce costs.

Journal Article > Commentary

Teaching quality improvement.

Murray ME, Douglas S, Girdley D, Jarzemsky P. J Nurs Educ. 2010;49:466-469.

This commentary outlines an educational program for nursing students designed to prepare them for involvement in quality improvement work.

Journal Article > Study

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

Discussion of adverse events in morbidity and mortality (M&M) conferences serves as an important tool for both educational and quality improvement initiatives. This study found that 80% of cases reviewed in monthly psychiatry M&M conferences at a children's hospital provided opportunities for patient care improvement.

Tools/Toolkit > Multi-use Website

Enteral Nutrition Safety Toolkit.

American Society for Parenteral and Enteral Nutrition; 8630 Fenton Street, Suite 412, Silver Spring, MD 20910.

This Web site includes a toolkit, posters, and educational materials to support safe tube feedings and prevent tubing misconnections. 

Book/Report

Advances in Patient Safety: New Directions and Alternative Approaches.

  • Classic

Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).

The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.

Back to Top