Related Links
RECENT QSEN ARTICLES
First, Do No Harm - Clinical Journal of Oncology Nursing (Spring 2009)
Rewriting the book on quality and safety - Emory Nursing Magazine (Fall 2008)
- Urologic Nursing: Special Issue on Quality Improvement (December 2008)
Quality and Nursing: Moving From a Concept to a Core Competency
Urinary Incontinence Quality Improvement in Nursing Homes: Where Have We Been? Where Are We Going?
Root Cause Analysis Following Nephrectomy After Extracorporeal Shockwave Lithotripsy (ESWL)
Tubing Misconnections - A Systems Failure With Human Factors: Lessons for Nursing Practice
Please note: the following articles require a free Medscape registration
BOOKS, REPORTS & OTHER RESOURCES
Advances in Patient Safety: From Research to Implementation
Vols. 1-4, AHRQ Publication Nos. 050021 (1-4). February 2005. Agency for Healthcare Research and Quality, Rockville, MD. This compendium describes the progress of federally-funded programs toward understanding medical errors and implementing programs to improve patient safety. Sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense - Health Affairs, the compendium covers a wide range of research paradigms, clinical settings, and patient populations. In addition to articles with a research and methodological focus, it includes articles addressing implementation issues or present useful tools and products that can be used to improve patient safety.
Classics (AHRQ Patient Safety Network
AHRQ PSNet editors have selected a set of "Classics": review articles, empirical studies, reports, and books that have special relevance to patient safety.
Culture Clues - University of Washington Medical Center
Culture Clues™ are tip sheets for clinicians, designed to increase awareness about concepts and preferences of patients from diverse cultures.
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This toolkit is designed to be used as a reference to structure "handoffs" and patient care transitions. The intent is to provide guidance in the form of background information, tools, strategies for improving handoffs, recommendations to provider staff based on JCAHO requirements, human factors research, scientific evidence, and identifiable best practices.
Institute of Medicine Health Care Quality Initiative
In 1996, the Institute of Medicine (IOM) launched an ongoing effort focused on assessing and improving the nation's quality of care, which is now in its third phase. The initiative has published these reports:
Integrating Quality Project (Association of American Medical Colleges)
The Integrating Quality initiative is an organizational performance improvement project that was developed to assist AAMC members in enhancing their dual quality goals of providing outstanding clinical care today while educating the outstanding physicians of tomorrow. The initiative includes three phases that were developed using the AAMC's "Learn, Serve, Lead" model, and involves identifying and making available key resources and QI strategies, as well as developing a network of individuals and partner organizations working to integrate these approaches in their medical centers.
National Center for Nursing Quality (ANA)
This site contains information on topics which address the safety and quality of nursing care patients receive and the quality of nurses' work lives. NCNQ® is the overarching entity which includes a number of projects focused on patient safety, nursing care quality, nurse safety and quality of work life, and the factors that impact these areas.
Nine Patient Safety Solutions (JCAHO and WHO)
The purpose of these solutions is to guide the re-design of care processes to prevent inevitable human errors from actually reaching patients. An individual solution will present the problem, the strength of evidence supporting the solution, potential barriers to adoption, risks of unintended consequences created by the solution, patient and family roles in the solution, and references and other resources.
Nursing Outlook. 2007:55:117-158
Quality and Safety Education for Nurses (Theme Issue). This issue covers a variety of topics related to quality and safety education for nurses, including the integration of safety content into daily work and an assessment of available educational opportunities.
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This paper was commissioned by the Picker Institute to explore what it will take to achieve more rapid and widespread implementation of patient-centered care in both inpatient ambulatory health care settings. The findings and recommendations are based largely on interviews with opinion leaders selected for their experience and expertise in either designing or implementing strategies for achieving excellence in patient-centered care.
Patient Safety Glossary (AHRQ)
Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. ARHQ has tried to adopt the most straight-forward terminology, with definitions that enjoy the widest use.
Patient Safety Tools: Improving Safety at the Point of Care (AHRQ)
These 17 toolkits were produced under AHRQ's Partnerships in Implementing Patient Safety (PIPS) grant program. They encompass a variety of evidence-based tools, including training materials, medication guides and checklists that can be adapted to other institutions and care settings. The tools were developed in the field and are designed to be implemented by multidisciplinary users.
Quality Grand Rounds Series in the Annals of Internal Medicine
This series of 13 case studies on patient safety was published in the Annals of Internal Medicine and supported by the California HealthCare Foundation. The cases, published over four years and presented during grand rounds at several hospitals, are based on real experiences and include expert analyses. In an effort to provide practical assistance in promoting cultures that support higher-quality care and patient safety, the articles in the series are available free of charge.
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This consensus statement from the Harvard Hospitals focuses on rapid and open disclosure and emotional support to patients and families who experience serious incidents. It also addresses ways to support and educate clinicians involved in such incidents. Two principles guide the recommendations for responding to incidents: medical care must be safe, and it must be patient-centered.
TEACHING MODULES & SCENARIOS
AHRQ - Morbidity and Morality Rounds on the Web - Nursing
Presents illustrative cases of medical errors, accompanied by expert commentaries, references, and opportunities to earn continuing medical education (CME) credits and continuing educational units (CEUs). It also includes a section on perspectives on safety and a "Did You Know?" section. AHRQ WebM&M is modeled on hospital morbidity and mortality conferences; three cases are posted each month to illustrate diverse patient safety issues, and case discussions are provided.
Evidence Based Nursing - Tutorial
(Health Sciences Library, UNC-Chapel Hill)The goal of this website is the investigation of the field of Evidence Based Nursing. It serves as an introduction to the topic, which could be used to create a more in-depth tutorial.
Ending the Document Game - Nurse Stories
Nurses and other health care providers relate the importance of information technology in providing timely, safe patient care.
TeamSTEPPS - Team Strategies and Tools to Enhance Performance & Patient Safety
TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among healthcare professionals. It includes a comprehensive collection of ready-to-use materials and training curricula necessary to integrate teamwork principles into all areas of a healthcare system. It was developed by the Department of Defense Patient Safety Program, in collaboration with the Agency for Healthcare Research and Quality.
Teamwork as a Tool for Patient Safety - Module
This course focuses on two techniques for effective communication that have been found successful in health care: (1) improving collaboration through briefings, and (2) promoting appropriate assertiveness within teams.
How to Use SBAR, Advocacy and Team Behaviors to Improve Patient Outcomes
The goals of this scenario are (1) to identify opportunities in the scenario where SBAR can be used to improve the quality of the communication between the providers and with the patient, (2) to identify opportunities where providers can use assertion to effectively advocate for the patient, and (3) to identify opportunities where team behaviors might have improved the care delivered to the patient.
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This program offers a practical introduction to human factors and how they relate to medical mishaps.
Committed to Safety: Ten Case Studies on Reducing Harm to Patients (Commonwealth Fund)
This report presents ten case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas for improving patient safety: promoting an organizational culture of safety, improving teamwork and communication, enhancing rapid response to prevent heart attacks and other crises in the hospital, preventing health care-associated infections in the intensive care unit, and preventing adverse drug events throughout the hospital. The cases describe the actions taken, results achieved, and lessons learned by these patient safety leaders, with suggestions for those seeking to replicate their successes.
Nursing and Patient Safety (NPSF)
Developed by nurses and other heatlhcare professionals to provide information on patient safety to nurses in all care settings, this website is a collaborative effort of the Agency for Health Research and Quality, the National Patient Safety Foundation, and the Medical College of Wisconsin.
- Institute for Healthcare Improvement
IHI Open School for Healthcare Professionals offers six basic courses in the areas of quality improvement and patient safety, and with plans to add more to this free site.
ORGANIZATIONS
- Academy for Healthcare Improvement
- AHRQ Patient Safety Network
- American Association of Colleges of Nursing (AACN)
- AORN Patient Safety First - Resources
- Essentials of Baccalaureate Education for Professional Nursing Practice (AACN)
- 5 Millon Lives Campaign (IHI)
- Hallmarks of Quality and Patient Safety (AACN)
- Institute for Family-Centered Care
- JCAHO Patient Safety
- Massachusetts Coalition for the Prevention of Medical Errors
- Medication Safety Tools and Resources (Institute for Safe Medication Practices)
- National League for Nursing
- National Patient Safety Foundation
- The NC Center for Hospital Quality and Patient Safety
- Patient-Centered Care (IHI)
- Patient Safety (IHI)
- Sigma Theta Tau International
- Ten Patient Safety Tips for Hospitals (AHRQ)
- Technology Informatics Guiding Education Reform-The TIGER Initiative
- Transforming Care at the Bedside (IHI and Robert Wood Johnson Foundation)
- VA National Center for Patient Safety