Narrow Results Clear All
- Patient Safety Primers 7
- WebM&M Cases 159
Perspectives on Safety
- Interview 48
- Perspective 43
- Commentary 567
- Review 193
- Study 989
- Slideset 6
- Book/Report 280
- Legislation/Regulation 89
- Newspaper/Magazine Article 282
- Newsletter/Journal 5
- Special or Theme Issue 84
- Toolkit 44
- Web Resource 262
- Award 14
- Bibliography 3
- Clinical Guideline 17
- Grant 9
- Meeting/Conference 27
- Press Release/Announcement 36
Communication between Providers
- Sbar 3
- Communication between Providers 262
- Culture of Safety 426
Education and Training
- Simulators 24
- Students 15
Error Reporting and Analysis
- Error Analysis 264
- Error Reporting 256
Human Factors Engineering
- Checklists 96
Legal and Policy Approaches
- Regulation 51
- Logistical Approaches 82
- Policies and Operations 8
Quality Improvement Strategies
- Benchmarking 251
- Reminders 76
- Six Sigma 23
- Research Directions 17
- Specialization of Care 104
- Teamwork 166
- Clinical Information Systems 175
- Transparency and Accountability 9
- Alert fatigue 6
- Device-related Complications 161
- Diagnostic Errors 204
- Discontinuities, Gaps, and Hand-Off Problems 226
- Drug shortages 9
- Failure to rescue 2
- Fatigue and Sleep Deprivation 24
- Identification Errors 76
- Inpatient suicide 2
- Interruptions and distractions 19
- Delirium 9
- Medication Errors/Preventable Adverse Drug Events 476
- MRI safety 8
- Nonsurgical Procedural Complications 85
- Overtreatment 8
- Psychological and Social Complications 83
- Second victims 3
- Surgical Complications 312
- Transfusion Complications 12
- Home Care 22
- Operating Room 234
- General Hospitals 637
- Long-Term Care 52
- Outpatient Surgery 37
- Patient Transport 14
- Psychiatric Facilities 12
- Allied Health Services 13
- Dentistry 4
- Critical Care 154
- Dermatology 10
- Gynecology 74
- Cardiology 36
- Geriatrics 74
- Hematology 16
- Nephrology 11
- Pulmonology 16
- Neurology 24
- Obstetrics 80
- Pediatrics 181
- Primary Care 97
- Radiology 63
- Nursing 196
- Palliative Care 5
- Pharmacy 218
- Family Members and Caregivers 33
Health Care Executives and Administrators
- Nurse Managers 162
- Risk Managers 251
Health Care Providers
- Nurses 315
- Pharmacists 143
- Physicians 441
Non-Health Care Professionals
- Educators 133
- Engineers 35
- Media 14
- Policy Makers 229
- Patients 184
- Africa 7
- China 6
- Australia and New Zealand 80
- Central and South America 6
- United Kingdom 290
- Canada 104
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 191
- United States Federal Government 257
Search results for "Quality Improvement Strategies"
- Quality Improvement Strategies
Meeting/Conference > Oregon Meeting/Conference
Oregon Patient Safety Commission. March 15, 2019; Sentinel Hotel, Portland, OR.
This conference will feature sessions presenting tools and practices that help all health care settings move forward in their patient safety work with an emphasis on creating environments that support psychological safety. Featured speakers include Dr. Jo Shapiro. The event will also recognize exemplars from Oregon's Patient Safety Reporting Program.
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Journal Article > Commentary
Dixon-Woods M. Clin Med (Lond). 2019;19:47-56.
The United Kingdom National Health Service (NHS) is known for both patient safety achievements and failures. This commentary discusses the unique opportunity the NHS embodies to improve practice. Highlighting system-level challenges due to lack of resources and funding, the author describes the role of health care professions in fostering continued achievements through the application of improvement science.
Patient Safety Primers
Most safety improvement efforts justifiably emphasize system performance. A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.
Patient Safety Primers
A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that more than 20% of patients in these settings experience an adverse event during their stay.
Patient Safety Primers
Triggers have become a widely used method of retrospectively analyzing medical records in order to identify errors and adverse events, measure the frequency with which such events occur, and track the progress of safety initiatives over time.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
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.
Journal Article > Commentary
Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles.
McCraw B, Crutcher T, Polancich S, Jones P. J Healthc Qual. 2018;40:392-397.
Although central line–associated bloodstream infections (CLASBI) have been a target of safety improvement efforts, they continue to occur in health care. This project report outlines a bundled approach to reducing CLASBIs in an intensive care unit that focused on team collaboration, communication, and evaluation. These elements were built on high reliability principles to establish a culture that contributed to the program's sustained improvements.
Journal Article > Study
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154:e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Web Resource > Multi-use Website
2501 Nelson Miller Parkway. Louisville, KY, 40223.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Journal Article > Commentary
Mann S, Hollier LM, McKay K, Brown H. N Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
Tools/Toolkit > Fact Sheet/FAQs
Gray D, Azam I. Rockville, MD: Agency for Healthcare Research and Quality; October 2018. AHRQ Publication No. 18(19)-0033-4-EF.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements in areas of focus such as hospital-acquired infections. The most recent update documented more than two-thirds improvement in patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Special or Theme Issue
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.
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.
Journal Article > Study
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Journal Article > Review
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.