Overviews of Quality Improvement
Roadmap for Quality Improvement - A guide for doctors (2006) . Very useful overview for clinicians from Manoj Jain, MD endorsed by CMS, the Institute for Healthcare Improvement, and Brent James, MD, a national safety and QI leader. Downloadable in pdf format -- 15 minute read.
Reinertsen JL. Institute for HealthCare Improvement. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (2008); Engaging Physicians in a Shared Quality Agenda (2007)
Batalden PB and Davidoff F. Qual. Saf. Health Care (2007) What is "quality improvement" and how can it transform healthcare?
Kilo CM and Larson EB. Exploring the Harmful Effects of Health Care. JAMA (2009)
Medical Error and Patient Safety
Institute of Medicine
Crossing the Quality Chasm (2001)
Knowing What Works in Healthcare (2008)
Agency for Healthcare Research and Quality (AHRQ)
10 Safety Tips for Hospitals ( 2007)
30 Safe Practices for Better Health Care ( 2005)
Atul Gawande
The Checklist (New Yorker December 2007)
Donald Berwick
The Science of Improvement (JAMA 2008) Comments on alternative QI experimental designs
Ambulatory Safety and Error
Woods QSHC 2007 Ambulatory care adverse events leading to a hospital admission
Kennedy A IJQHC 2008 Using nurses / office staff to report prescribing errors in primary care
International Comparisons of U.S. Health Care
Commonwealth Fund -- Amenable Mortality in 19 Nations (Health Affairs 2008)
Diagnostic Error
Schiff 2002 Review of potential approaches in reducing error in diagnosis
Lindberg DA Intro: American J of Medicine supplemental issue on diagnostic error (2008)
Drug and Medication Safety
Analysis of settled malpractice claims by the Doctors Company, showed internal medicine, family practice and psychiatry to be involved in nearly half of all medication-related errors. Medication monitoring (43%) and dosage errors (26%) accounted for 69% of medication-related errors. Of the medication monitoring errors, one-third involved failing to properly monitor warfarin.
Budnitz Ann Int Med 2007 U.S. adults age 65+ have more than 175 000 emergency department visits for adverse drug events yearly. Medications counseled against in the elderly (Beers list) accounted for only 4% of these visits, while warfarin, insulin, and digoxin generated one third.
Mills Qual Safety in Health Care 2008 The most common types of ADE were "wrong dose", "wrong medication", "failed to give medication", and "wrong patient". Changes at the bedside and improvement in equipment and computers are effective at reducing ADEs. Well-organised tracking and support from leadership and staff were characteristics of facilities successful at improving outcomes. Training without action was associated with worse outcomes. abstract
Ross. Br J Clin Pharm 2009. What is the scale of prescribing errors committed by junior doctors? A systematic review. Literature heterogeneous. Range of error rates was 2–514 per 1000 items prescribed and 4.2–82% of pts or charts reviewed. Theme issue. article
Phillips Arch Int Med 2008 Domestic Fatal Medication Errors w/ Alcohol/ Street Drugs abstract
The Institute for Safe Medication Practices is a good resource on medication safety. website
Innovation Theory
AHRQ collection 2007-8 word doc
Inpatient Safety
Shojania Annals Int Med 2006 Graduate Medical Education and Patient Safety: A Busy and Occasionally Hazardous Intersection
Ranji S, Shojania K. Med Clin N Am 2008. Implementing patient safety interventions in your hospital: what to try and what to avoid. (targeted to hospitalists)
Medical Error and Service Quality
Taylor Medical Care 2008 This AHRQ-funded study used retrospective chart review to correlate patients' complaints of poor service quality with documented adverse event. Patient-reported instances of poor service quality were associated with double the risk of medical errors.
National Study of Medical Error Involving Trainees
Singh Arch Int Med 2007 Among 240 cases, errors in judgment (72%), teamwork breakdowns (70%), and lack of technical competence (58%) were most prevalent contributing factors.
Nursing Collaboration in Reducing Medical Error
Rogers QSHC 2008 Critical care nurses detected many errors using a 28-day log
Reliability Theory for Healthcare Processes
Institute for Healthcare Improvement (IHI) white paper
Safety Culture
Pace W JGIM 2007 . Measuring a Safety Culture: Critical Pathway or Academic Activity?
Sustainability Theory
Feldstein A. Review of quality intervention attributes favoring sustainability (JCJQPS 2008)
Team Work Training
Chakraborti C. Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education (JGIM 2008) Discusses current evidence base, which it describes as "modestly effective", assessing studies on Baker’s 8 teamwork principles. PubMed
Translational Theory
Pronovost PJ. Translating evidence into practice: a model for large scale knowledge translation. BMJ (2008) Article Model Powerpoint Slide
Woolf S. 2 articles on Translational Theory -- local adaptation general discussion JAMA (2008)
Quality-Related Journals
American Journal of Medical Quality
International Journal for Quality in Health Care
Joint Commission Journal of Quality and Patient Safety
Quality and Safety in Health Care
Quality Websites
Commonwealth Fund Why Not the Best? Benchmarks to Top 1% National Performers