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Patient Safety and Quality

An Evidence-Based Handbook for Nurses


Nurses play a vital role in improving the safety and quality of patient care—not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes.

To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality—Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043).

Experts in the field reviewed the literature, and their contributions are grouped into these sections:

Patient Safety and Quality / Evidence-based Practice / Patient-centered Care / Working Conditions—Work Environment / Critical Opportunities for Patient Safety and Quality / Tools

Select to download the Entire Volume as a PDF file (10 MB) or individual chapters (below). All PDF files are accessible. PDF Help.

Select for Ordering Information.


Edited by Ronda G. Hughes, Ph.D., M.H.S., R.N., of AHRQ

Contents

Introduction

Foreword:
Carolyn M. Clancy, M.D., and Risa Lavizzo-Mourey, M.D., M.B.A.

Preface—General Overview/Executive Summary:
Ronda G. Hughes, Ph.D., M.H.S., R.N.

Peer Reviewers

Contributing Authors

Acknowledgments

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Section I: Patient Safety and Quality

1. Defining Patient Safety and Quality Care (PDF file, 46.2 KB)
Pamela H. Mitchell, Ph.D., R.N., F.A.A.N.

2. Nurses at the "Sharp End" of Patient Care (PDF file, 210 KB)
Ronda G. Hughes, Ph.D., M.H.S., R.N.

3. An Overview of To Err Is Human— Re-emphasizing the Message of Patient Safety (PDF file, 75.7 KB)
Molla Sloane Donaldson, Dr.P.H., MS

4. The Quality Chasm Series: Implications for Nursing (PDF file, 130 KB)
Mary K. Wakefield, Ph.D., R.N.

5. Understanding Adverse Events: A Human Factors Framework (PDF file, 339 KB)
Kerm Henriksen, Ph.D.; Elizabeth Dayton; Margaret A. Keyes, M.A.; Pascale Carayon, Ph.D.; and Ronda G. Hughes, Ph.D., M.H.S., R.N.

6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically (PDF file, 132 KB)
Patricia E. Benner, Ph.D., R.N., F.A.A.N.; Ronda G. Hughes, Ph.D., M.H.S., R.N.; and Molly Sutphen, Ph.D.

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Section II: Evidence-based Practice

7. The Evidence for Evidence-Based Practice Implementation (PDF file, 455 KB)
Marita G. Titler, Ph.D., R.N., F.A.A.N.

8. Health Services Research: Scope and Significance (PDF file, 90.8 KB)
Donald M. Steinwachs, Ph.D., and Ronda G. Hughes, Ph.D., M.H.S., R.N.

9. Synergistic Opportunity to Connect Quality Improvement and Emergency Preparedness (PDF file, 136 KB)
Sally Phillips, Ph.D., R.N.; Ronda Hughes, Ph.D., M.H.S., R.N.; and Lucy Savitz, Ph.D., M.B.A.

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Section III: Patient-centered Care

10. Fall and Injury Prevention (PDF file, 612 KB)
Leanne Currie, Ph.D., R.N.

11. Reducing Functional Decline in Hospitalized Elderly (PDF file, 153 KB)
Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N.; Kathy Fletcher, R.N., G.N.P., A.P.R.N., B.C., F.A.A.N.; and Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.

12. Pressure Ulcers: A Patient Safety Issue (PDF file, 198 KB)
Courtney H. Lyder, N.D., G.N.P., F.A.A.N., and Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N.

13. Patient Safety and Quality in Home Health Care (PDF file, 293 KB)
Carol Hall Ellenbecker, Ph.D., R.N.;Linda Samia, R.N.; Margaret J. Cushman, R.N., F.H.H.C., F.A.A.N.; and Kristine Alster, Ed.D., R.N.

14. Supporting Family Caregivers in Providing Care (PDF file, 352 KB)
Susan C. Reinhard, Ph.D., R.N., F.A.A.N.; Barbara Given, Ph.D., R.N., F.A.A.N.; Nirvana Huhtala, and Ann Bemis

15. Pediatric Safety and Quality (PDF file, 201 KB)
Susan Lacey, Ph.D., R.N.; Janis B. Smith, R.N., M.S.N.; and Karen Cox, Ph.D., R.N.

16. Prevention–Safety and Quality (PDF file, 197 KB)
Carol Loveland-Cherry, Ph.D., R.N., F.A.A.N.

17. Improving the Quality of Care Through Pain Assessment and Management (PDF file, 193 KB)
Nancy Wells, Ph.D.; Chris Paseo, R.N., F.A.A.N.; and Margo McCaffery, R.N., F.A.A.N.

18. Medication Management of the Community-Dwelling Older Adult (PDF file, 308 KB)
Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N., and Lisa Antle, A.P.R.N., B.C., A.P.N.P.

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Section IV: Working Conditions and the Work Environment for Nurses

19. Care Models (PDF file, 82.3 KB)
Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.

20. Leadership (PDF file, 150 KB)
Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.; Joanne Disch, Ph.D., R.N., F.A.A.N., and Laura Senn, M.S., R.N.

(a) [Vignette] Transforming Health Care for Patient Safety: Nurses’ Moral Imperative to Lead (PDF file, 50.8 KB)
Diana Mason, Ph.D., R.N., F.A.A.N.

(b) [Vignette] Who Should Lead the Patient Quality/Safety Journey? (PDF file, 38.9 KB)
Joanne Disch, Ph.D., R.N., F.A.A.N.

(c) [Vignette] Creation of a Patient Safety Culture: A Nurse Executive Leadership Imperative (PDF file, 79.7 KB)
Victoria L. Rich, Ph.D., R.N., F.A.A.N.

21. Creating a Safe and High-Quality Health Care Environment (PDF file, 101 KB)
Patricia W. Stone, Ph.D., R.N.; Ronda G. Hughes, Ph.D., M.H.S., R.N.; and Maureen Dailey, R.N., M.S.

22. Practice Implications of Keeping Patients Safe (PDF file, 100 KB)
Ann Page, R.N., M.P.H.

23. Patient Acuity (PDF file, 69.5 KB)
Bonnie Jennings, D.N.Sc., R.N., F.A.A.N.

24. Restructuring and Mergers (PDF file, 119 KB)
Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.

25. Nurse Staffing and Patient Care Quality and Safety (PDF file, 233 KB)
Sean P. Clarke, Ph.D., R.N., C.R.N.P., F.A.A.N., and Nancy E. Donaldson, D.N.Sc., R.N., F.A.A.N.

26. Work Stress and Burnout Among Nurses: Role of the Work Environment and Working Conditions (PDF file, 171 KB)
Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.

27. Temporary, Agency, and Other Contingent Workers (PDF file, 57.6 KB)
Ann Page, R.N., M.P.H.

28. The Impact of Facility Design on Patient Safety (PDF file, 299 KB)
John G. Reiling, M.H.A., M.B.A.; Ronda G. Hughes, Ph.D., M.H.S., R.N.; and Mike R. Murphy, R.N., B.S.N., M.B.A.

29. Turbulence (PDF file, 77.3 KB)
Bonnie Jennings, D.N.Sc., R.N., F.A.A.N.

30. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective (PDF file, 96.3 KB)
Pascale Carayon, Ph.D., and Ayse P. Gurses, Ph.D.

31. Organizational Workflow and its Impact on Work Quality (PDF file, 198 KB)
Carol Cain, Ph.D., and Saira Haque, M.S.

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Section V: Critical Opportunities for Patient Safety and Quality Improvement

32. Professional Communication (PDF file, 159 KB)
Jean Ann Seago, Ph.D., R.N.

33. Professional Communication and Team Collaboration (PDF file, 117 KB)
Michelle O’Daniel, Ph.D., and Alan Rosenstein, M.D.

34. Handoffs: Implications for Nurses (PDF file, 358 KB)
Mary Ann Friesen, M.S.N., R.N., C.P.H.Q.; Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q.; and Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q.

35. Error Reporting and Disclosure (PDF file, 267 KB)
Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., and Ronda G. Hughes, Ph.D., M.H.S., R.N.

36. Wrong-Site Surgery: A Preventable Medical Error (PDF file, 122 KB)
Deborah Mulloy, M.S.N., R.N., and Ronda Hughes, Ph.D., M.H.S., R.N.

37. Medication Administration Safety (PDF file, 348 KB)
Ronda G. Hughes, Ph.D., M.H.S., R.N., and Mary Blegen, Ph.D., R.N., F.A.A.N.

38. Medication Reconciliation (PDF file, 96.5 KB)
Jane Barnsteiner, Ph.D., R.N.

39. Personal Safety for Nurses (PDF file, 295 KB)
Alison M. Trinkoff, Sc.D., R.N., F.A.A.N.; Jeanne M. Geiger-Brown, Ph.D., R.N.; Claire C. Caruso, Ph.D., R.N.; Jane A. Lipscomb, Ph.D., R.N., F.A.A.N.; Meg Johantgen, Ph.D., R.N.; Audrey L. Nelson, Ph.D., R.N., F.A.A.N. ;Barbara A. Sattler, Dr.P.H., R.N., F.A.A.N.; and Victoria L. Selby, R.N., B.S.N.

40. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety (PDF file, 278 KB)
Ann E. Rogers, Ph.D., R.N., F.A.A.N.

41. Preventing Health Care-Associated Infections (PDF file, 219 KB)
Amy Collins, M.P.H., R.N.

42. Targeting Health Care-Associated Infections: Evidence-Based Strategies (PDF file, 167 KB)
Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N.; Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N.; and Karen K. Giuliano, R.N., Ph.D., F.A.A.N.

43. Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality (PDF file, 231 KB)
Eileen O’Grady, Ph.D., R.N., N.P.

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Section VI: Tools for Quality Improvement and Patient Safety

44. Tools and Strategies for Quality Improvement and Patient Safety (PDF file, 299 KB)
Ronda G. Hughes, Ph.D., M.H.S., R.N.

45. AHRQ Quality Indicators (PDF file, 231 KB)
Marybeth Farquhar, R.N., M.S.N.

46. Magnet Environments for Professional Nursing Practice (PDF file, 222 KB)
Vicki Lundmark, Ph.D.

47. Patient Safety and Health Information Technology: Role of the Electronic Health Record (PDF file, 274 KB)
Nancy Staggers, Ph.D., R.N., F.A.A.N.; Charlene Weir, Ph.D., R.N.; and Shobha Phansalkar, R.Ph., M.S.

48. Patient Safety, Telenursing, and Telehealth (PDF file, 242 KB)
Loretta Schlachta-Fairchild, Ph.D., F.A.C.H.E.; Victoria Elfrink, Ph.D., R.N.B.C.; and Andrea Deickman, M.S.N., R.N.

49. Documentation and the Nurse Care Planning Process (PDF file, 206 KB)
Gail Keenan, Ph.D., R.N.; Elizabeth Yakel, Ph.D.; and Dana Tschannen, Ph.D., R.N.; and Mary Mandeville, M.B.A.

50. Patient Care Technology and Safety (PDF file, 123 KB)
Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N.; Audrey L. Nelson, Ph.D., R.N., F.A.A.N.; and Emily S. Patterson, Ph.D.

51. Enhancing Patient Safety in Nursing Education Through Patient Simulation (PDF file, 303 KB)
Carol Fowler Durham, M.S.N., R.N., and Kathryn R. Alden, M.S.N., R.N., I.B.C.L.C.

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Ordering Information

The handbook can be ordered on a single CD-ROM (AHRQ Publication No. 08-0043-CD) or as a set of three printed volumes (AHRQ Publication N0. 08-0043). Select for Electronic Order Form.

Current as of April 2008


Internet Citation:

Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043). Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nurseshdbk/


 

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