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We invite you to leverage these external resources we've found helpful.


CMS Measure Management System- Valuable Resource in Understanding Quality Measures

Centers for Medical and Medicaid Services System Management Overview. CMS Measure Management System - Valuable Resource in Understanding Quality Measures  

AHRQ Patient Safety Primer on High Reliability

High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. High reliability is an ongoing process of cultivating organizational mindfulness; standardization is necessary but not sufficient for achieving resilient and reliable health care systems.AHRQ Patient Safety Network - High Reliability

Leveraging Data to Transform Nursing Care: Insights From Nurse Leaders

This study was undertaken to gain insight into how nurse leaders are influencing the use of performance data to improve nursing care in hospitals. Two themes emerged: getting relevant, reliable, and timely data into the hands of nurses and the leaders' ability to "connect the dots" in working with different stakeholders. Study findings may inform nurse leaders in their efforts to leverage data to transform nursing care.

AHRQ’s Guide to Patient and Family Engagement in Hospital Quality and Safety

Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, the Agency for Healthcare Research and Quality (AHRQ) developed a guide to help patients, families, and health professionals work together as partners to promote improvements in care. To access the full guide go to:

AHRQ’s Patient Safety Network Offers Primer on Efforts to Prevent "Never Events”.

Health care organizations are under increasing pressure to eliminate "Never Events," which are medical errors such as wrong-site surgery that should never have occurred. Though they rarely occur, these 29 events may indicate fundamental safety problems within a health care organization. AHRQ’s Patient Safety Network (PSNet) offers a primer that describes these events, which of them are most commonly reported, and current national efforts to encourage health care organizations to report, analyze and disclose such errors in order to improve quality. To access the full patient safety primer titled "Never Events" go to:

Help for healthcare professionals to understand organizational compliance.

Regulation and Accreditation, Diane Storer Brown, PhD, RN, CPHQ, FNAHQ, FAAN - Senior Scientist, Collaborative Alliance for Nursing Outcomes, December 2011. Reference material to help healthcare professionals understand the overarching structure for organizational compliance. The first section focuses on regulation, the second section focuses on accreditation and certification, and the third section brings together the program infrastructure for continuous regulatory and accreditation readiness. Access the report here.

AHRQ Toolkit Can Help Hospitals Lower Preventable Readmissions.

The Agency for Healthcare Research and Quality has sponsored hundreds of patient safety research and implementation projects, in this report they offer 10 evidence-based tips to prevent adverse events from occurring in your hospital.Ten Patient Safety Tips for Hospitals.


ED Throughput


Improving Patient Flow and Reducing Emergency Department Crowding

An AHRQ Guide for Hospitals



When and how to use restraints

Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others. This is a an article from Gale Springer, RN, MSN, PMHCNS-BC. The full text is available from American Nurse today at

Falls and fall-related injuries in hospitals.

Clinics in Geriatric Medicine, Nov. 2010. D. Oliver, et al. (2010, Nov). Clinics in Geriatric Medicine.  645-692
Becker, C., & Rapp, K.  (2010). Falls prevention in Nursing Homes. Clinics in Geriatric Medicine.  693-704.

Special Issue:  Falls in the Older Adult.

Clinical Nursing Research, An International Journal. 21(1) Feb. 2012: Spoelstra, S. L., Given, B.A., & Given, C.W. (2012).  Fall prevention in hospitals:  An integrative review. Clinical Nursing Research. 21(1). 92-112)

Fall prevention in the elderly:  Analysis and comprehensive review of methods used in the hospital and the home.

Clyburn, T.A., & Heydemann, J.A. (2011).  J. of Am. Academy of Orthopedic Surgeons. 19(7):  402-409.

Partnering to Prevent Falls. Using a Multimodal Multidisciplinary Team.

An organizational goal to decrease fall rates was initiated using a multidisciplinary, multimodal approach. One innovative strategy was the Friday fall review, where nurse managers present each fall that occurred to determine causes and potential preventive measures. Results of the project include a fall rate below the benchmark for 9 of 10 recent consecutive quarters. Because of the success of this initiative, the quality department has adopted the format to review all core measure indicators where there is noncompliance or less than optimal performance.The Journal of Nursing Administration. June 2013 - Volume 43 - Number 6 - pp 336-341. Select to access the article on

An Insider's View on Fall Prevention.

An NP with a history of falls argues that we can do better. AJN, American Journal of Nursing. April 2013 - Volume 113 - Issue 4 - p 11. Select to access the article on AJN.

Report Says Effectiveness Studies of Hospital Fall Prevention Methods Need Improvement.

Promising interventions exist for preventing hospital patients from falling, but the authors of a new AHRQ-funded literature review found that only a small proportion reported sufficient data to evaluate their effectiveness. To better determine effectiveness, a new report from AHRQ’s Southern California Evidence-based Practice Center says that interventions should include better outcomes documentation, more information about comparison groups, and details about the components, implementation, and adherence. The report authors analyzed 59 studies published over 28 years that met their inclusion criteria. "Hospital Fall Prevention: A Systematic Review of Implementation, Components, Adherence, and Effectiveness,” was published online on March 25 in the Journal of the American Geriatrics Society. Select to access the abstract on PubMed.


Reconceptualizing Patient Safety Attendants.

Alexandra Wiggins, MSN, RN, NEBC; Cheryl Welp, BSN, RN, CNML; and Dana N. Rutledge, PhD, RN. Nursing Management, May 2012; 43(5):25-27. Describes the assessment and plan to reduce usage of patient safety attendants (PSAs) or sitters at St. Joseph Hospital in Orange, California.

New AHRQ Resource Can Help Prevent Patient Falls in Hospitals

The Agency for Healthcare Research and Quality has a new online toolkit, "Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care," that focuses on reducing falls that occur during a patient’s hospital stay. Nearly one million patients fall in U.S. hospitals each year. The Toolkit is organized under six major areas that address hospital readiness, program management, choosing fall prevention practices, implementation, measurement, and sustainability. Fall prevention programs require an interdisciplinary approach to care in order to manage a patient’s underlying fall risk factors, such as problems with walking and transfers, medication side effects, confusion, and frequent toileting needs. To find out more, visit

Healthcare Acquired Infections 

Healthcare-associated Infections (HAI) Progress Report

The HAI Progress Report describes significant reductions reported at the national level in 2013 for nearly all infections. CLABSI and SSI show the greatest reduction, with some progress shown in reducing hospital-onset MRSA bacteremia and hospital-onset C. difficile infections. The Report shows an increase in CAUTI, signaling a strong need for additional prevention efforts.Click here to read the full article.

Health Care Failure Mode and Effect Analysis to Reduce NICU Line–Associated Bloodstream Infections

A health care failure mode and effect analysis team identified 5 common failure modes that contribute to the development of CLABSIs. These included contamination, suboptimal environment of care, improper documentation and evaluation of central venous catheter dressing integrity, issues with equipment and suppliers, and lack of knowledge. Since implementing the appropriate action plans, the NICU has experienced a significant decrease in CLABSIs from 2.6 to 0.8 CLABSIs per 1000 line days. Click here to read the full article.

The Drive to Zero Surgical Site Infections

The focus on surgical site infection (SSI) prevention has never been more important given current trends in health care, including the ongoing shift from inpatient to outpatient ORs, non-reimbursement for health care associated-infections, and mandated public reporting of infection rates in some states. Click here to read the full article.

Guide to Preventing Catheter-Associated Urinary Tract Infections (CAUTI)

The guide is available from The Association for Professionals in Infection Control and Epidemiology (APIC) as a free download, it contains updated content on the epidemiology and causes of CAUTI, as well as detailed information on surveillance and reporting. Developed by a team of infection prevention experts, the guide also features new content that addresses patient safety, the Comprehensive Unit-based Safety Program (CUSP), and other behavioral models for CAUTI prevention. Additionally, this guide includes new information on CAUTI prevention in special populations, including pediatric, spinal cord injury, long-term care, and intensive care unit patients. Distribution of this guide as an online resource from the APIC website is made possible by the Agency for Healthcare Research & Quality (AHRQ) through the national On the CUSP: Stop CAUTI project.

Hand Hygiene Information and Tools from the VA

AHRQ Report Provides Blueprint for National Effort To Reduce Catheter-Associated Urinary Tract Infections

A report on an AHRQ-funded project published in the October issue of Infection Control and Hospital Epidemiology (ICHE) identifies key components of a national project to reduce catheter-associated urinary tract infection (CAUTI) in more than 1,500 participating hospital units. The report and an abstract of a journal article, titled "Implementing a National Program to Reduce Catheter-Associated Urinary Tract Infection: A Quality Improvement Collaboration of State Hospital Associations, Academic Medical Centers, Professional Societies, and Governmental Agencies,” explain how the project has leveraged the expertise of different organizations to reduce catheter-related harm. Key components of the national project are centralized coordination of the effort and dissemination of information, data collection based on established definitions and approaches, focused guidance on the technical practices that will prevent CAUTI, emphasis on understanding program socio-adaptive aspects, and partnering with specialty organizations and governmental agencies that have expertise in reducing healthcare-associated infections. In addition to the ICHE article, AHRQ recently released an interim data report on the progress so far in this national project of hospital units that are implementing the Comprehensive Unit-based Safety Program to prevent CAUTI.

Video Features Clinicians Discussing the Power of CUSP Toolkit to Reduce Infections

AHRQ's Comprehensive Unit-based Safety Program (CUSP) toolkit can help your clinical teams build the capacity to address patient safety challenges on the front lines of care. Find out how clinicians in the field are using this tool to eliminate healthcare-associated infections in their facilities. To learn more about CUSP and how it was developed, watch the video What Is CUSP? .
The CUSP toolkit is free and available online at

CDC Study: Prevention Led to 200,000 Fewer Bloodstream Infections.

Hospitals report mixed results in protecting patients from infections
Hospitals in the U.S. continue to make progress in the fight against central line-associated bloodstream infections and some surgical site infections, but did not see improvement in catheter-associated urinary tract infections between 2010 and 2011, according to a new report issued by the Centers for Disease Control and Prevention (CDC). 
CDC reported for 2011:

  • A 41 percent reduction in central line-associated bloodstream infections since 2008, up from the 32 percent reduction reported in 2010. Progress in preventing these infections was seen in intensive care units (ICU), wards, and neonatal ICUs in all reporting facilities. CDC estimates that 12,400 central line-associated bloodstream infections occurred in 2011, costing one payer, the Centers for Medicare & Medicaid Services (CMS), approximately $26,000 per infection.
  • A 7 percent reduction in catheter-associated urinary tract infections since 2009, which is the same percentage of reduction that was reported in 2010. While there were modest reductions in infections among patients in general wards, there was essentially no reduction in infections reported in critical care locations.
  • The full report is available at

Medication Administration

Nursing Strategies to Increase Medication Safety in Inpatient Settings

This article provides nursing recommendations to decrease medication delivery errors through strategies to minimize and address interruptions/distractions. CALNOC is cited as the training method for medication administration observation. Link to abstract

Pediatric Medication Administration Errors and Workflow Following Implementation of a Bar Code Medication Administration System

This pilot study identified a low rate (5%) of medication administration errors and fair compliance with the six safety processes on two pediatric units and one neonatal unit following Bar Code Medication Administration implementation.

Using Lean “Automation with a Human Touch” to Improve Medication Safety: A Step Closer to the “Perfect Dose”

Ching, Joan M.; Williams, Barbara L.; Idemoto, Lori M.; Blackmore, C. Craig. The Joint Commission Journal on Quality and Patient Safety. Volume 40, Number 8, August 2014, pp. 341. Virginia Mason Medical Center (Seattle) employed the Lean concept of Jidoka (automation with a human touch) to plan for and deploy bar code medication administration (BCMA) to hospitalized patients. Link to abstract

Using Lean to Improve Medication Safety: In Search of the “Perfect Dose”

Ching, Joan; Long, Christina; Williams, Barbara; Blackmore, Craig. The Joint Commission Journal on Quality and Patient Safety. Volume 39, Number 5, May 2013, pp. 195. At Virginia Mason Medical Center (Seattle), the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study was used in combination with Lean quality improvement efforts to address medication administration safety.. Link to abstract

Predictors of Unit-Level Medication Administration Accuracy: Microsystem Impacts on Medication Safety

This study tested multivariate models exploring unit-level predictors of medication administration (MA) accuracy. J Nurs Adm. June 2014. Link to abstract

Computerized Provider Order Entry Reduces Medication Errors in Hospitals

Processing a prescription through an electronic ordering system can reduce the likelihood of a drug error by half and potentially avoid more than 17 million such incidents in U.S. hospitals in one year alone, according to a new study supported by the Agency for Healthcare Research and Quality. The authors evaluated published evidence on the impact of computerized provider order entry (CPOE) on hospital drug errors and combined this information with data on the adoption of CPOE and the volume of medication orders processed annually. The results estimated the reduction in drug errors for one year, finding that widespread adoption of CPOE could substantially reduce drug errors. "Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems” appears online in the Journal of the American Medical Informatics Association.To access the abstract, select:

Patient Safety Primer Offers Strategies to Prevent Medication Errors

A growing evidence base supports specific strategies to prevent adverse drug events (ADEs), according to a patient safety primer posted online on AHRQ’s Patient Safety Network (PSNet). The primer outlines strategies providers can use at each stage of the medication use pathway – prescribing, transcribing, dispensing, administration – to prevent ADEs. These strategies range from computerized provider order entry and clinical decision support to minimizing nurse disruption and providing better patient education and medication labeling. The primer also identifies known risk factors for ADEs, including health literacy, patient characteristics, high alert medications and transitions in care.
To access the full patient safety primer, titled Medication Errors, go to:   

Lessons from America's Safest Hospital

This article from AARP Magazine profiles medical centers and their efforts to reduce medical errors.

Patient Safety

New AHRQ Brochure Helps Organizations Effectively Choose a Patient Safety Organization

A new regulation from the Centers for Medicare & Medicaid Services allows qualified health plans to meet the requirements of the Affordable Care Act by contracting with hospitals that work with Patient Safety Organizations (PSOs). Download AHRQ’s new brochure.  


When and How to Use Restraints

Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others. This is a an article from Gale Springer, RN, MSN, PMHCNS-BC. The full text is available from American Nurse today at

What You Can Do to Improve Hand Hygiene

A leader guide on how to improve your HH Compliance. Use this Unit/Service leader checklist periodically to remind yourself of what you can do to improve hand hygiene on your unit/service.

Nix the Noise: Managing Alarms, Alerts and Interruptions

As new technologies are developed and adopted across healthcare settings, the problem continues to grow, forcing organizations to reach beyond previous attempts to drive chatter out of the hospital.

15 Statistics on Patient Safety, Distribution of HAIs

Statistics on hospital-acquired conditions, adverse events and patient safety extracted from chapter three, "Patient Safety Importance," from the 2012 National Healthcare Quality Report, produced by the Agency for Healthcare Research and Quality.


Pressure Ulcers

National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury

To learn more about hospital acquired pressure ulcer (HAPU) prevention:
  • Baharestani, M. 2008 Deep Tissue Injuries: Clinical insights. Symposium on Advanced Wound Care, San Diego, CA .
  • Bates-Jensen, B. (2001). Bates-Jensen Wound Assessment Tool.
  • Baumgarten, B. Margolis, D. Localio, A. et al.(2006) Pressure ulcers among elderly patients early in the hospital stay. Journal of Gerontologoy: Medical Sciences 61A (7):749-755.
  • Beeckman, D, Van Lancker, A, Van Hecke, A., Verhaeghe, S. (2014) A systematic review and meta analysis of incontinence associated dermatitis, incontinence and moisture as risk factors for pressure ulcer development, Res. Nurs Health, June, 37(3), 204-218.
  • Braden, B. and J. Maklebust (2005). "Preventing Pressure Ulcers with the Braden Scale: An update on this easy-to-use tool that assesses a patient's risk." American Journal of Nursing 105(6): 70-72
  • Butler, C. (2009). Pediatric Skin Care: Guidelines for assessment, prevention and treatment. Dermatology Nursing.
  • CALNOC Website Tutorial: using your hospital-wide logon (only CALNOC participating hospitals will have access to this tutorial).
  • Coyer FM, Stotts NA, Blackman, VS. A prospective window into medical device-related pressure ulcers in intensive care. Int Would J 2013; doi: 10.1111/iwj.12026
  • Dorner, B., Posthauer, M., Thomas, D. (2009).The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. NPUAP, Available through the NPUAP website,
  • Gunningberg, L. (2005). Are patients with or at risk of pressure ulcers allocated appropriate prevention measures? International Journal of Nursing Practice 11(2): 58-67.
  • Institute for Healthcare Improvement: Prevent Pressure Ulcers—Getting Started Kit at
  • National Pressure Ulcer Advisory Panel (NPUAP):
  • NPUAP (2007). Pressure Ulcer Prevention Points. Available through the NPUAP website,
  • NPUAP and EPUAP (2009) International Guideline: Prevention of Pressure Ulcers: Quick Reference Guide. Available through the NPUAP website,
  • Perioperative Pressure Ulcers prevention toolkit is available from the Association of periOperative Registered Nurses at
  • Schindler, C. et al. (2011). Protecting fragile skin: Nursing interventions to decrease development of pressure ulcers in pediatric care. AM J Critical Care.
  • Stotts, N. and L. Gunningberg (2007). "Predicting Pressure Ulcer Risk, Using the Braden Scale with Older Hospitalized Adults: the Evidence Supports It." American Journal of Nursing 107(11): 40-48. 
  • Suleman, L and Percival, S. Biofilm-Infected pressure ulcers: Current knowledge and emerging treatment strategies. Biofilm-based Healthcare Associated Infections, 2(29-43).
  • Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention and Management of Pressure Ulcers. WOCN: Glenview, IL.


When and how to use restraints

Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others. This is a an article from Gale Springer, RN, MSN, PMHCNS-BC. The full text is available from American Nurse today at

Standards BoosterPakTM

for Use of Restraint and Seclusion for Organizations Using Joint Commission Accreditation for Deemed Status. Published by The Joint Commission Accreditation 2013.

Practice parameters

identified by professional groups for specific populations in regards to aggressive behavior, seclusion and restraint. These include the following:
• Child & Adolescent:
American Academy of Child & Adolescent Psychiatry: Practice Parameter for the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions, With Special Reference to Seclusion and Restraint
• Special Needs Population:
National Association of State Mental Health Program Directors: Reducing the Use of Seclusion and Restraint
PART II: Findings, Principles, and Recommendations for Special Needs Populations
• American Psychiatric Nursing Association: Seclusion & Restraint Position Statement :
• National Association of Psychiatric Health Systems: Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health


Examining the Value of Inpatient Nurse Staffing: An Assessment of Quality and Patient Care Costs

A recent study using data from the Agency for Healthcare Research and Quality (AHRQ) showed that increases in hospital nurse staffing levels are associated with reductions in adverse events and lengths of stay. In addition, the study found that increased staffing levels do not lead to increased cost. 

California Nurses: Taking the Pulse.

This report provides an overview of California’s nursing workforce, including supply and demographics, education, distribution, and compensation. Provided by the California Healthcare Foundation.

Reconceptualizing Patient Safety Attendants

Alexandra Wiggins, MSN, RN, NEBC; Cheryl Welp, BSN, RN, CNML; and Dana N. Rutledge, PhD, RN. Nursing Management, May 2012; 43(5):25-27. Describes the assessment and plan to reduce usage of patient safety attendants (PSAs) or sitters at St. Joseph Hospital in Orange, California.

An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality.

Ann Kutney-Lee, Douglas M. Sloane and Linda H. Aiken. HealthAffairs. March 2013 vol. 32 no. 3 579-586. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, the authors found a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients. 





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