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Patient Safety and Quality:
An Evidence-Based
Handbook for Nurses
Agency for Healthcare Research and Quality
U.S. Departme...
This document is in the public domain and may be used and reprinted without
permission, except those copyrighted materials...
Foreword
The Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson
Foundation (RWJF) are pleased t...
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iv
Preface
Errors pervade our lives in our homes, on the roads, and in our places of work. Each hour of
each day, patients an...
various aspects of safety and quality employed cross-sectional study designs, predominately
representing assessments at si...
continually assess, understand, and meet the needs of patients and prepare themselves to meet
emerging health needs we mig...
to organize inpatient care services for patients (chapter 19); whether or not the organization
embraces and is committed t...
protective barriers (chapter 41), and strategies to address ventilator-acquired pneumonia (chapter
42).
The influence of n...
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x
Peer Reviewers
Daleen Aragon—Orlando Regional
Healthcare, FL
William Baine—AHRQ, MD
Mary Barton—AHRQ, MD
Mary Blegen—Unive...
Contributing Authors
Kathryn Rhodes Alden, M.S.N., R.N.,
I.B.C.L.C.
University of North Carolina at Chapel
Hill
Kristine A...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Mary Ann Friesen, M.S.N., R.N., C.P.H.Q.
Center for Amer...
Contributing Authors
Sally Phillips, Ph.D., R.N.
Agency for Healthcare Research and
Quality
Gail Powell-Cope, Ph.D., A.R.N...
Acknowledgments
Without a doubt, this could not have been accomplished without the contribution and
dedication of many peo...
Contents
Foreword
Carolyn M. Clancy, M.D., and Risa Lavizzo-Mourey, M.D., M.B.A.
Preface – General Overview/Executive Summ...
14. Supporting Family Caregivers in Providing Care
Susan C. Reinhard, Ph.D., R.N., F.A.A.N., Barbara Given, Ph.D., R.N., F...
28. The Impact of Facility Design on Patient Safety (Draft—Do Not Reproduce)
John G. Reiling, M.H.A., M.B.A., Mike R. Murp...
Section VI: Tools for Quality Improvement and Patient Safety:
44. Quality Methods, Benchmarking, and Measuring Performance...
Chapter 1. Defining Patient Safety and Quality Care
Pamela H. Mitchell
Introduction
The goal of this chapter is to provide...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Patient Safety
A definition for patient safety has emerg...
Defining Patient Safety, Quality Care
problem are classified in terms of type (error), communication (failures between pat...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
nurse and physician cognitive diagnostic and treatment d...
Defining Patient Safety, Quality Care
9. Committee on the Quality of Health Care in America.
Crossing the quality chasm: A...
Chapter 2. Nurses at the “Sharp End” of Patient Care
Ronda G. Hughes
Background
The work environment in which nurses provi...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
organization than others because resources can b...
Nurses at the “Sharp End”
assert that work-arounds could introduce errors when the underlying work processes and
workflows...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
by pharmacists can be intercepted by nurses, and...
Nurses at the “Sharp End”
the resource requirements, the complex nature of changing practice, and the influences of units
...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
Yet, many organizations do not meet the standard...
Nurses at the “Sharp End”
IOM has advocated for hospitals to transition into HROs to improve the quality and safety of
car...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
mindful, as manifested by being preoccupied with...
Nurses at the “Sharp End”
competencies that reflect the nature of nursing in improving patient and systems outcomes,
inclu...
Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1
management have better outcomes than those patie...
Nurses at the “Sharp End”
surgical errors)152
and higher mortality.153
Poor teamwork as well as disrespectful, rude, and
i...
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