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 single file (  PDF version - 9.8 MB) or see Chapters to view (or download) individual chapters.

Select for Ordering Information.

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

Chapters

Introduction

Introduction: Forward, Preface, Peer Reviewers, Contributing Authors, [ - 114.01 KB]

• Foreword: Carolyn M. Clancy, M.D., and Risa Lavizzo-Mourey, M.D., M.B.A.
• Preface: 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 version - 46.29 KB)
  Pamela H. Mitchell, Ph.D., R.N., F.A.A.N.
• 2. Nurses at the "Sharp End" of Patient Care (  PDF version - 373.12 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 version - 75.77 KB)
  Molla Sloane Donaldson, Dr.P.H., MS
• 4. The Quality Chasm Series: Implications for Nursing (  PDF version - 130.26 KB)
  Mary K. Wakefield, Ph.D., R.N.
• 5. Understanding Adverse Events: A Human Factors Framework (  PDF version - 346.38 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 version - 132.73 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 version - 488.02 KB)
  Marita G. Titler, Ph.D., R.N., F.A.A.N.
• 8. Health Services Research: Scope and Significance (  PDF version - 90.87 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 version - 136.2 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 version - 612.02 KB)
  Leanne Currie, Ph.D., R.N.
• 11. Reducing Functional Decline in Hospitalized Elderly (  PDF version - 153.85 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 version - 198.79 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 version - 293.95 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 version - 352.19 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 version - 201.58 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 version - 198 KB)
  Carol Loveland-Cherry, Ph.D., R.N., F.A.A.N.
• 17. Improving the Quality of Care Through Pain Assessment and Management (  PDF version - 199.36 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 version - 308.87 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 version - 82.38 KB)
  Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.
• 20. Leadership (  PDF version - 150.67 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 version - 50.84 KB)
    Diana Mason, Ph.D., R.N., F.A.A.N.
  • (b) [Vignette] Who Should Lead the Patient Quality/Safety Journey? (  PDF version - 38.96 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 version - 80.07 KB)
    Victoria L. Rich, Ph.D., R.N., F.A.A.N.
• 21. Creating a Safe and High-Quality Health Care Environment (  PDF version - 101.34 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 version - 122.28 KB)
  Ann Page, R.N., M.P.H.
• 23. Patient Acuity (  PDF version - 69.57 KB)
  Bonnie Jennings, D.N.Sc., R.N., F.A.A.N.
• 24. Restructuring and Mergers (  PDF version - 119.99 KB)
  Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.
• 25. Nurse Staffing and Patient Care Quality and Safety (  PDF version - 233.46 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 version - 171.73 KB)
  Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N.
• 27. Temporary, Agency, and Other Contingent Workers (  PDF version - 57.66 KB)
  Ann Page, R.N., M.P.H.
• 28. The Impact of Facility Design on Patient Safety (  PDF version - 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 version - 83.51 KB)
  Bonnie Jennings, D.N.Sc., R.N., F.A.A.N.
• 30. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective (  PDF version - 96.39 KB)
  Pascale Carayon, Ph.D., and Ayse P. Gurses, Ph.D.
• 31. Organizational Workflow and its Impact on Work Quality (  PDF version - 340.74 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 version - 159.49 KB )
  Jean Ann Seago, Ph.D., R.N.
• 33. Professional Communication and Team Collaboration (  PDF version - 117.74 KB )
  Michelle O'Daniel, Ph.D., and Alan Rosenstein, M.D.
• 34. Handoffs: Implications for Nurses (  PDF version - 358.65 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 version - 278.06 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 version - 144 KB )
  Deborah Mulloy, M.S.N., R.N., and Ronda Hughes, Ph.D., M.H.S., R.N.
• 37. Medication Administration Safety (  PDF version - 348.82 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 version - 96.59 KB )
  Jane Barnsteiner, Ph.D., R.N.
• 39. Personal Safety for Nurses (  PDF version - 322.64 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 version - 278.65 KB )
  Ann E. Rogers, Ph.D., R.N., F.A.A.N.
• 41. Preventing Health Care-Associated Infections (  PDF version - 351.96 KB )
  Amy Collins, M.P.H., R.N.
• 42. Targeting Health Care-Associated Infections: Evidence-Based Strategies (  PDF version - 173.15 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 version - 237.06 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 version - 287.93 KB)
  Ronda G. Hughes, Ph.D., M.H.S., R.N.
• 45. AHRQ Quality Indicators (  PDF version - 231.88 KB)
  Marybeth Farquhar, R.N., M.S.N.
• 46. Magnet Environments for Professional Nursing Practice (  PDF version - 222.61 KB)
  Vicki Lundmark, Ph.D.
• 47. Patient Safety and Health Information Technology: Role of the Electronic Health Record (  PDF version - 274.13 KB , 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 version - 402.45 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 version - 342.23 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 version - 123.95 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 version - 303.83 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

To request a copy of the 1,400-page handbook on a searchable CD-ROM (AHRQ Publication No. 08-0043-CD), contact the AHRQ Publications Clearinghouse via E-mail at ahrqpubs@ahrq.hhs.gov or by calling 800-358-9295.