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- Study 1
- Slideset 1
- Legislation/Regulation 13
- Special or Theme Issue 4
- Toolkit 4
- Web Resource 78
- Bibliography 1
- Meeting/Conference 4
- Communication between Providers 16
- Culture of Safety 67
- Education and Training 47
Error Reporting and Analysis
- Error Reporting 33
- Human Factors Engineering 17
Legal and Policy Approaches
- Regulation 10
- Logistical Approaches 6
Quality Improvement Strategies
- Benchmarking 40
- Research Directions 4
- Specialization of Care 7
- Teamwork 17
- Clinical Information Systems 5
- Transparency and Accountability 1
- Device-related Complications 7
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 16
- Drug shortages 2
- Identification Errors 6
- Medical Complications 40
- Medication Errors/Preventable Adverse Drug Events 14
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 5
- Surgical Complications 24
- Transfusion Complications 2
- Internal Medicine 80
- Surgery 17
- Nursing 9
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- Family Members and Caregivers 7
- Health Care Executives and Administrators 246
Health Care Providers
- Nurses 12
- Physicians 16
Non-Health Care Professionals
- Media 3
- Patients 32
- Australia and New Zealand 5
- Europe 59
- Canada 9
- United States of America 211
Search results for "Quality Improvement Strategies"
- Quality Improvement Strategies
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
World Health Assembly A72/26 72nd session. Geneva, Switzerland: World Health Organization; March 29, 2019.
This guidance summarizes the current status of global patient safety, highlights World Health Organization efforts to address the problem, and provides direction for WHO leadership and policy makers to achieve improvements in safety. Recommendations include universal health coverage, coordination of efforts, and dissemination of effective practices.
Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
The role of hospital boards in influencing and financing efforts to improve safety is of recognized importance. However, leaders must have the skills and mindset needed to understand and perform quality governance responsibilities. This report provides a framework drawn from the Institute of Medicine six elements of quality to clarify responsibilities of trustees and health system leaders with regard to quality oversight.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Patient Safety Learning: London, UK; September 2018.
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report outlines existing challenges and strategies to drive system improvement, including leadership engagement, shared learning, patient safety data optimization, and building on expertise from other high-risk industries.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Boston, MA: Institute for Healthcare Improvement; 2018.
The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence assessment to provide recommendations to improve the safety of home-based care. The document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered care, safety culture, learning and improvement systems, team-based and coordinated care provision, and incentive models.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
In: 2018 Comprehensive Accreditation Manual for Hospitals. CAMH. Oakbrook Terrace, IL: Joint Commission; January 2018:PS1-PS50.
This chapter provides information about how organizations can re-design existing programs or launch new initiatives working to meet National Patient Safety Goal and accreditation standards. The material focuses on the importance of integrating safety and quality work with frontline activities, evaluating progress of interventions, and learning from critical events to guide improvements.
Oakbrook Terrace; IL: Joint Commission; 2017.
The Joint Commission annual report provides performance data for United States hospitals across a range of accountability measures and highlights changes associated with quality measurement. In 2016, hospital performance on accountability measures remained strong. Although the composite accountability score decreased slightly, this result is thought to be due to the fact that measures were retired that had high performance in the past. In 2016, 59.6% of hospitals achieved overall composite performance of greater than 95%. The report also describes the Pioneers in Quality program, which was designed to facilitate hospital reporting of electronic clinical quality measures. In 2016, 470 hospitals reported electronic clinical quality measure data compared to only 34 in 2015. In a PSNet interview, the president and chief executive officer of The Joint Commission discusses high reliability in health care.
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.
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017.
Morbidity and mortality from opioid medications constitutes a patient safety problem. This National Academy of Medicine report explores the role of physicians in preventing and treating opioid misuse. The report highlights the increasing rate of opioid prescriptions in parallel with rising numbers of opioid overdose deaths and recommends adherence to clinical guidelines on opioid use, specifically the 2016 CDC guideline. The authors call for improved access to opioid prescription and dispensing data and more stringent regulation of opioid medications. They provide detailed recommendations for clinicians to prescribe opioids more safely, including the use of prescription drug monitoring programs, coprescription of naloxone, and engaging with community resources to identify and treat opioid use disorder. A recent PSNet perspective discussed opioid overdoses as a patient safety problem.
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.
This publication compared the use of the Global Trigger Tool with a two-stage retrospective review process to design a method to monitor health care–associated harm in Welsh National Health Service hospitals. Analyzing results from 11 of the 13 system hospitals, investigators determined that a hybrid incident review approach that does not rely on physician involvement can return reliable data.
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.
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
London, UK: Royal College of Obstetricians and Gynaecologists; 2016.
This report highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm.
Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
Lean methodology focuses on establishing a culture that supports employee safety and drives process improvement. This book provides information about Lean and how to implement such concepts to integrate quality and safety behaviors in health care delivery. One chapter focuses on the use of root cause problem-solving and error prevention. The author spoke about applying Lean in hospitals in a previous PSNet interview .
Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-EHC022-EF.
Efforts to maintain patient autonomy can detract from ensuring residents' safety in nursing homes. Common safety issues in nursing homes are medication errors, falls, and inappropriate use of restraints. This technical brief discusses gaps in the research base that hinder understanding of the safety hazards in the residential care environment.
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.
Boston, MA: National Patient Safety Foundation; 2016.
Scoville R, Little K, Rakover J, Luther K, Mate K. Cambridge, MA: Institute for Healthcare Improvement; 2016.
Numerous activities and programs have been launched to improve patient safety, but sustaining improvements can be challenging. This white paper provides a framework that draws from key quality improvement concepts and Lean management tactics to help organizations integrate safety improvements in clinicians' daily work over time.