Patient Safety and Quality: 

An Evidence-Based 

Handbook for Nurses 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

Editor: 

Ronda G. Hughes, Ph.D., M.H.S., R.N. 

AHRQ Publication No. 08-0043-CD 

March 2008 

Disclaimer: The opinions expressed in this document are those of the authors 

and do not reflect the official position of AHRQ or the U.S. Department of Health 

and Human Services. 
This document is in the public domain and may be used and reprinted without 

permission, except those copyrighted materials noted for which further reproduction is 

prohibited without specific permission of the copyright holder. Citation of the source is 

appreciated. 

Suggested Citation: 

Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. 

(Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication 

No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. 

ii
Foreword 

The Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson 

Foundation (RWJF) are pleased to have jointly sponsored the development of this handbook for 

nurses on patient safety and quality. Patient Safety and Quality: An Evidence-Based Handbook 

for Nurses examines the broad range of issues involved in providing high quality and safe care 

across health care settings. 

We know that nurses are at the center of patient care and therefore are essential drivers of 

quality improvement. From the Institute of Medicine’s reports, including To Err is Human and 

Keeping Patient’s Safe: Transforming the Work Environment of Nurses, we know that patient 

safety remains one of the most critical issues facing health care today and that nurses are the 

health care professionals most likely to intercept errors and prevent harm to patients. For us, both 

at AHRQ and RWJF, improving patient safety and health care quality is embedded in our 

mission and at the core of what we do. 

We strongly believe that the safety and quality of health care in this nation is dependent upon 

the availability of the best research possible and on our ability to deliver the results of that 

research into the hands of providers, policymakers, and consumers so that all can make better 

decisions. We believe the result will be improved health care and safety practices, which will be 

manifested in measurably better outcomes for patients. 

Given the diverse scope of work within the nursing profession in this country, AHRQ and the 

RWJF expect that the research and concepts presented in the book will be used to improve health 

care quality by nurses in practice, nurse-educators, nurse-researchers, nursing students, and 

nursing leaders. The 89 contributors to this book represent a broad range of nurse-researchers 

and senior researchers throughout this nation. 

The product of this joint effort underscores the commitment of AHRQ and the RWJF to 

achieving a health care system that delivers higher quality care to everyone. We believe that 

high-quality health care can be achieved through the use of evidence and an enabled and 

empowered nursing workforce. 

We welcome written comments on this book. They may be sent to Ronda Hughes, Agency 

for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. 

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

Director President and CEO 

Agency for Healthcare Research Robert Wood Johnson Foundation 

and Quality 

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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 and clinicians are affected by near errors and the consequences of adverse 

events. The effects of health care errors and poor quality health care have impacted all our 

lives—sometimes directly, at other times indirectly. Even during the writing of this book, many 

of the authors had firsthand experiences with near errors, adverse events, and a level of poorquality care that should never have been presented to any patient. Given the importance of health 

and health care in our lives, the purpose of this book is to bring safety and quality to the forefront 

in nursing. 

Throughout these pages, you will find peer-reviewed discussions and reviews of a wide range 

of issues and literature regarding patient safety and quality health care. Owing to the complex 

nature of health care, this book provides some insight into the multiple factors that determine the 

quality and safety of health care as well as patient, nurse, and systems outcomes. Each of these 

51 chapters and 3 leadership vignettes presents an examination of the state of the science behind 

quality and safety concepts and challenges the reader to not only use evidence to change 

practices but also to actively engage in developing the evidence base to address critical 

knowledge gaps. Patient safety and quality care are at the core of health care systems and 

processes and are inherently dependent upon nurses. To achieve goals in patient safety and 

quality, and thereby improve health care throughout this nation, nurses must assume the 

leadership role. 

Despite being a relatively new field of inquiry, particularly in terms of how patient safety and 

quality are now defined, the need to improve the quality and safety of care is the responsibility of 

all clinicians, all health care providers, and all health care leaders and managers. As clinicians, 

we are obligated to do our best, regardless of whether we are acting as a clinician or a patient. 

Just as we say there are “good patients” and “bad patients,” clinicians as patients can 

unfortunately be considered “bad patients” because they may know too much, ask too many 

questions, or are not up-to-date on the research or current practice standards. Yet that is a 

mindset that must end and become a part of history, not to be repeated. Instead, nurses need to 

ensure that they and other team members center health care on patients and their families. All 

patients—whether they include ourselves, our loved ones, or the millions of our neighbors 

throughout this country—need to be engaged with clinicians in their care. 

Each of the chapters in this book is organized with a background section and analysis of the 

literature. At the end of each chapter, you will find two critical components. First, there is a 

“Practice Implications” section that outlines how the evidence can be used to inform practice 

changes. Practice leaders and clinicians can use this information, based on the state of the 

science, to guide efforts to improve the quality and safety of delivering services to patients. 

Second, there is a “Research Implications” section that outlines research gaps that can be 

targeted by researchers and used by clinicians to inform and guide decisions for practice. Faculty 

and graduate students will find innumerable questions and issues that can be used to develop 

dissertation topics and grant applications to uncover the needed evidence.

In all but a few chapters, you will find evidence tables. These tables were developed by 

critically assessing the literature, when possible, and present invaluable insight as to the type and 

quality of research that can inform practice, clarify knowledge gaps, and drive future research. 

As the reader will observe, the majority of patient safety and quality research presented in the 

evidence tables represent cross-sectional studies. In fact, 81 percent of the studies exploring the 

v
various aspects of safety and quality employed cross-sectional study designs, predominately 

representing assessments at single sites of care and using qualitative surveys. This may be the 

byproduct of the challenges of the research process (including sources of funding) or the 

challenges of engaging in collaborative research. From this review of the literature, we can learn 

the importance of the need for longitudinal, multisite analyses to bring us forward into the next 

generation of evidence-based knowledge. 

Great is the importance of nurses being involved throughout the research process and 

collaborating with interdisciplinary teams throughout care settings. Then, too, it is critical that 

nursing leaders and managers, clinical leaders, and nurses across care settings engage in a 

lifelong pursuit of using data and information as well as research evidence to inform practice. 

Combined with experiential knowledge, analyses, and evidence, nurses will be challenged to 

continuously improve care processes and encourage our peers and interdisciplinary colleagues to 

make sure patients receive the best possible care, regardless of where they live, their race or 

gender, or their socioeconomic circumstances. 

The chapters in this book are organized into six sections. Each chapter can be read 

independently of the others; however, some do make reference to other chapters, and a greater 

understanding of the breadth and depth of patient safety and quality can be better obtained by 

reading the book in its entirety. Highlights from the chapters are summarized by section as 

follows: 

In Section I – Patient Safety and Quality, patient safety is discussed as being foundational to 

quality, where nurses can be invaluable in preventing harm to patients and improving patients’ 

outcomes (chapter 1). Even though the quality and safety of health care is heavily influenced by 

the complex nature of health care and multiple other factors, nurses have been held accountable 

for harm to patients, even when other clinicians and health care providers and characteristics of 

the care system in which they work often have—almost without exception—greater roles and, in 

some respects, have ensured that an error would happen (chapters 2 and 3). With the many 

challenges facing health care today, the Institute of Medicine’s 11-volume Quality Chasm series 

brings to light the multitude of issues and factors that individuals and organizations, both within 

and outside of nursing and health care, need to understand and to work together to overcome 

(chapter 4). Moving toward and securing a culture of safety throughout health care will, by 

definition, acknowledge the influence of human factors in all clinicians, the results of humansystem interfaces and system factors, and will institutionalize processes and technology that will 

make near errors and errors very rare (chapter 5). This paradigm shift will enable nurses to think 

more critically and clinically (chapter 6), and to achieve greater insights as to how education, 

training, and experience are needed and can be leveraged to ultimately achieve high-quality care 

in every care setting and for all patients. 

To improve patient safety and quality, one needs to understand the state of the science at 

hand, as well as strategies that can be behind effective utilization of evidence and 

implementation of change, as discussed in Section II – Evidence-Based Practice. It is here that 

one can learn that implementing evidence into practice can be accomplished though several 

approaches—often more than one simple intervention is possible—and by early on engaging key 

stakeholders to move toward adoption of change by translating research-based evidence into 

everyday care (chapter 7). Yet in assessing the state of the science, it becomes apparent that the 

majority of care afforded patients is not evidence based, emphasizing the need for health services 

research to examine progress toward safer and higher-quality care and to assess new and 

innovative practices (chapter 8). While the future of health care is uncertain, clinicians must 

vi
continually assess, understand, and meet the needs of patients and prepare themselves to meet 

emerging health needs we might not expect (chapter 9). 

Due to innumerable pressures to improve patient safety and quality, it may be important to 

focus on those areas of care delivery, as discussed in Section III – Patient-Centered Care, that 

are significantly influenced by nursing care. Providing health care is all about patients and their 

needs and meeting those care needs in settings where the majority of care is provided by 

clinicians—or, in certain circumstances, where loved ones and family members supplement 

nursing care or solely provide for the care needs of patients in community settings. Almost all 

the adverse events and less-than-optimal care afforded patients can be prevented, beginning by 

implementing research in practice. Situations in which failure to use evidence can be detected 

can include when preventable patients falls with injury occur (chapter 10), when illness-related 

complications are missed and lead to functional decline in the elderly (chapter 11), and when 

pressure ulcers develop in patients of any age (chapter 12). For nurses, ensuring and/or providing 

evidence-based, safe, and high-quality care become even more challenging when patients need 

care in their homes and subsequently rely on care rendered by family members and loved ones—

care that can be dependent upon the guidance of nurses (chapter 13). Not only can the resources 

and functionality of the community or home setting pose potential threats to the safety of patients 

and may relegate them to care of a lower quality, but those who care for patients may also 

succumb to the physical and emotional demands of providing informal care; amelioration can 

require broadening nursing care to caregivers (chapter 14). 

Nursing can also have a significant effect on the outcomes of specific groups of patients, 

particularly in preventing not only adverse events but the lasting effects of comorbidities and 

symptoms. The reason behind focusing on these specific populations is that their unique needs 

must not be considered less important than those of the majority. In the case of children, who are 

some of the most vulnerable patients due to developmental and dependency factors, it is difficult 

to provide safe, high-quality care that meets their unique needs. Instead, nurses need to use 

current best practices (chapter 15) to avert potentially lifelong comorbidities and address 

symptoms—and develop new practices when the evidence is not available. It is also important to 

focus on simple strategies to prevent morbidity—not just preventing adverse events—and ensure 

that patients receive preventive care services whenever possible, especially when the use of these 

services is supported by evidence (chapter 16). Especially for patients with moderate to severe 

pain, it is also important to prevent the adverse effects of their diseases and conditions by 

working with patients to manage their pain, promoting healing and improving function (chapter 

17). And finally, in the case of potential adverse effects of polypharmacy in the elderly, nurses 

can also focus on simple strategies to improve adherence to intended therapies and detect 

unnecessary side effects, thereby improving medication safety (chapter 18). 

Beyond the influence of evidence on quality processes and outcomes, there are health care 

system and organization factors and characteristics to consider. As discussed in Section IV – 

Working Conditions and the Work Environment for Nurses, evidence concerning the impact of 

health care system factors illustrates that working conditions and the work environment, which 

are heavily influenced by leaders, can have a greater impact on the safety and quality of health 

care than what an individual clinician can do. Instead of aggregating the various aspects of 

working conditions, the chapters in this section define and focus on specific aspects of key 

factors associated with patient and systems outcomes, centering on the importance of leadership. 

The leadership and management of health care organizations and health systems are pivotal 

to safer and higher quality of care because they direct and influence: which model of care is used 

vii
to organize inpatient care services for patients (chapter 19); whether or not the organization 

embraces and is committed to fostering and sustaining a climate of safety and high-quality care 

(chapter 21); the impact of external factors, and the functionality and organization of 

microsystems within the context of the organization and relationships with others (chapter 22); 

how the specific care needs of patients are met with sufficient numbers of the right types of 

nurses (chapter 23 and chapter 25); how resource allocations and cost-saving strategies that 

involve restructuring, mergers, and organizational turbulence impact care delivery and patient 

outcomes (chapter 24 and chapter 29); the type of work environment that influences work stress 

and patient outcomes (chapter 26 and chapter 27); and how the actual physical environment and 

care processes influence the workload and workflow of nursing care (chapter 28, chapter 30, 

chapter 31). 

Taken together, leadership throughout organizations, led by nurse executives and influenced 

by physicians, is critical in determining whether or not safety and high-quality care can be 

achieved through daily teamwork, collaboration, and communication (chapter 20). It is because 

of the importance of senior nursing leadership that emphasis is put on the moral imperative that 

senior nursing leadership has to lead health care in the quest for safer and higher-quality care 

(vignette a), to demonstrate the right type of leadership (vignette b), and to excel in the right 

competencies (e.g., business skills and principles, communication and relationship management, 

and professionalism) (vignette c). 

Nursing leaders must actively work with and enable staff to transform the current work 

climate and care delivery. Section V – Critical Opportunities for Patient Safety and Quality 

Improvement puts forth several critical opportunities that leaders and staff can work together to 

achieve success. In almost every care setting and situation, effective communication is essential. 

Not only do clinicians need to constantly communicate in a professional and technical way 

(chapter 32) and with team members in a way that is respectful and attuned to individual 

differences (chapter 33), clinicians must also ensure that the right information is communicated 

to next caregiver or health care provider so that the safety and quality of care is not compromised 

(chapter 34). 

Other opportunities for improvement center on the necessity to continually assess near errors 

and errors, not only those events that harm patients, and put in place strategies to avert the 

recurrence of both the near error and errors. Assessing and evaluating near errors and errors—

and the ability to avert the recurrence of errors—is dependent upon having information that is 

reported by clinicians (chapter 35), so that some errors (e.g., wrong-site surgery) never happen 

(chapter 36). Many initiatives to improve patient safety and health care quality have focused on 

medication safety. While many medication errors are prevented from harming patients because a 

nurse detected the error, monitoring and evaluating both near misses and adverse drug events can 

lead to the adoption of strategies to decrease the opportunities for errors, including unit dosing, 

using health information technology (chapter 37), and reconciling a patient’s medications 

(chapter 38). 

The nature of the work and the stress of caregiving can place nurses and patients at risk for 

harm. Moving patients, being in close proximity to therapeutic interventions, the implications of 

shift work and long work hours (chapter 39 and chapter 40), and ignoring the potential risk of 

injury and the impact of fatigue can increase the risk of occupational injury. It follows then that, 

because of the nature of the work, the proximity of nurses to patients, and the chronic and acute 

needs of patients, particular attention must be given to preventing health care–associated 

infections through known effective strategies, such as environmental cleanliness, hand hygiene, 

viii
protective barriers (chapter 41), and strategies to address ventilator-acquired pneumonia (chapter 

42). 

The influence of nurse practitioners and of the new generation of doctorate-level nurse 

clinicians has the potential of enabling significant improvements in critical opportunities for 

patient safety and quality improvement (chapter 43). The opportunities to demonstrate the 

influence of these clinical leaders is endless. The last section of this book, Section VI – Tools for 

Quality Improvement and Patient Safety, focuses on the strategies and technologies that can be 

used to push health care to the next level of quality. One of the tools that can be used is quality 

methods, including continuous quality improvement, root cause analysis, and plan-do-study-act 

(chapter 44). Quality and patient safety indicators can also be used to assess performance and 

monitor improvement (chapter 45). These, as well as other tools, are integral in efforts to develop 

and demonstrate nursing excellence (chapter 46). With recent developments in information 

technologies, there are many potential benefits that can be afforded by these technologies that 

can facilitate decisionmaking, communication of patient information (chapter 47, chapter 48, 

chapter 49), therapeutic interventions (so long as the information technologies are used and 

function properly) (chapter 49), and education and training (chapter 51). 

All of these various issues and factors come together to define the complexity and scope of 

patient safety and quality care but also the necessity for multifaceted strategies to create change 

within health care systems and processes of care. In using evidence in practice, engaging in 

initiatives to continually improve quality, and striving for excellence, nurses can capitalize on the 

information from this book and lead health care in the direction that it should and needs to be 

heading to better care for the needs of patients. What it all comes down to is for us, as nurses, to 

decide what kind of care we would want as patients then to do all that is possible to make that 

happen. Today we may be doing what we can, but tomorrow we can improve. With this evidence 

and the call to action to nurses, in 5 years from now, headlines and research findings should 

carry forth the message that there are significant improvements in the quality and safety of health 

care throughout this nation, and it was because nurses led the way. 

Ronda G. Hughes 

Editor 

ix
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x
Peer Reviewers 

Daleen Aragon—Orlando Regional 

Healthcare, FL 

William Baine—AHRQ, MD 

Mary Barton—AHRQ, MD 

Mary Blegen—University of California at 

San Francisco, CA 

Barbara Braden—Creighton University, NE 

Nancy Bergstrom—University of Texas, 

Houston, TX 

Peter Bruehaus—Vanderbilt University, TN 

Helen Burstin—National Quality Forum, 

DC 

Carol Cain—Kaiser Permante, CA 

Carolyn Clancy—AHRQ, MD 

Sean Clarke—University of Pennsylvania, 

PA 

Marilyn Chow—Kaiser Permante, CA 

Beth Collins-Sharp—AHRQ, MD 

Kathy Crossen—AHRQ, MD 

Linda Lindsey Davis—Duke University, NC 

Ellen Mockus D’Errico—Loma Linda 

University, CA 

Joanne Disch—University of Minnesota, 

MN 

Anita Hanrahan—Capital Health, 

Edmonton, Alberta 

Aparana Higgins—Booz | Allen | Hamilton, 

NY 

Kerm Henrickson—AHRQ, MD 

Judith Hertz—Northern Illinois University, 

IL 

Ronda Hughes—AHRQ, MD 

Rainu Kaushal—Harvard-Partners, MA 

Ron Kaye—FDA, MD 

Marge Keys—AHRQ, MD 

Christine Kovner—New York University, 

NY 

Jeanette Lancaster—University of Virginia, 

VA 

David Lanier—AHRQ, MD 

Elaine Larson—Columbia University, NY 

Kathy Lee—University of California at San 

Francisco, CA 

Michael Leonard—Kaiser Permante, CA 

Sally Lusk—University of Michigan, MI 

David Meyers—AHRQ, MD 

Jack Needleman—University of California 

at Los Angeles, CA 

D.E.B. Potter—AHRQ, MD 

Peter Pronovost—Johns Hopkins University, 

MD 

Amanda Rischbieth—Australia 

Carol Romano—DHHS/USPHS, MD 

Judy Sangel - AHRQ, MD 

Cynthia Scalzi—University of Pennsylvania, 

PA 

Carol Scholle—University of Pittsburgh 

Medical Center Presbyterian Hospital, PA 

Jean Ann Seago—University of California 

at San Francisco, CA 

Joan Shaver—University of Illinois at 

Chicago, IL 

Maria Shirey—Shirey & Associates, IN 

Jean Slutsky—AHRQ, MD 

Kaye Spence—Children’s Hospital at 

Westmead, Sydney, Australia 

Janet Tucker—University of Aberdeen, 

United Kingdom 

Tasnim Vira—University of Toronto, 

Ontario 

Judith Warren—University of Kansas, KS 

Jon White—AHRQ, MD 

Zane Robinson Wolf—La Salle University, 

PA 

Laura Zitella—Stanford University Cancer 

Center, CA 

xi
Contributing Authors 

Kathryn Rhodes Alden, M.S.N., R.N., 

I.B.C.L.C. 

University of North Carolina at Chapel 

Hill 

Kristine Alster, Ed.D., R.N. 

University of Massachusetts at Boston 

Lisa Antle, A.P.R.N., B.C., A.P.N.P 

University of Wisconsin Milwaukee 

College of Nursing 

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. 

Advances in Skin and Wound Care

Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N. 

University of Pennsylvania School of 

Nursing and Hospital of the University of 

Pennsylvania 

Ann Bemis, M.L.S. 

Rutgers, The State University of New 

Jersey 

Patricia Benner, R.N., Ph.D., F.A.A.N. 

Carnegie Foundation for the Advancement 

of Teaching 

Mary A. Blegen, Ph.D., R.N., F.A.A.N. 

School of Nursing, University of 

California, San Francisco 

Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., 

C.P.H.Q. 

College of Nursing, University of Central 

Florida, Orlando 

Carol H. Cain, Ph.D. 

Care Management Institute, Kaiser 

Permanente 

Pascale Carayon, Ph.D. 

University of Wisconsin-Madison 

Claire C. Caruso, Ph.D., R.N. 

National Institute for Occupational Safety 

and Health 

Sean P. Clarke, R.N., Ph.D., C.R.N.P., 

F.A.A.N. 

University of Pennsylvania School of 

Nursing 

Amy S. Collins, B.S., B.S.N., M.P.H. 

Centers for Disease Control and 

Prevention 

Karen Cox, R.N., Ph.D., C.N.A.A., 

F.A.A.N. 

Children’s Mercy Hospitals and Clinics, 

Kansas City, MO 

Leanne Currie, D.N.Sc., M.S.N., R.N. 

Columbia University School of Nursing 

Margaret J. Cushman, Ph.D.(c), R.N., 

F.H.H.C., F.A.A.N. 

University of Massachusetts at Boston 

Maureen Ann Dailey, R.N., M.S. 

Columbia University School of Nursing 

Elizabeth Dayton, M.A. 

Johns Hopkins University 

Andrea Deickman, M.S.N., R.N. 

iTelehealth Inc. 

Joanne Disch, Ph.D., R.N., F.A.A.N. 

University of Minnesota School of 

Nursing 

Molla Sloane Donaldson, Dr.P.H., M.S. 

M.S.D. Healthcare 

Nancy E. Donaldson, R.N., D.N.Sc., 

F.A.A.N. 

University of California, San Francisco, 

School of Nursing 

Carol Fowler Durham, M.S.N., R.N., 

University of North Carolina at Chapel 

Hill 

Victoria Elfrink, Ph.D., R.N.B.C. 

College of Nursing of Ohio State 

University and iTelehealth Inc. 

Carol Hall Ellenbecker, Ph.D., R.N. 

University of Massachusetts at Boston 

Marybeth Farquhar, R.N., M.S.N., C.A.G.S. 

Agency for Healthcare Research and 

Quality 

Kathy Fletcher, R.N., G.N.P., A.P.R.N.-

B.C., F.A.A.N. 

University of Virginia Health System 

xii
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Mary Ann Friesen, M.S.N., R.N., C.P.H.Q. 

Center for American Nurses, Silver 

Spring, MD 

Jeanne M. Geiger-Brown, Ph.D., R.N. 

University of Maryland School of Nursing 

Karen K. Giuliano, R.N., Ph.D., F.A.A.N. 

Philips Medical Systems 

Barbara Given, Ph.D., R.N., F.A.A.N. 

Michigan State University College of 

Nursing 

Ayse P. Gurses 

University of Minnesota-Twin Cities 

Saira Haque, M.H.S.A., Doctoral candidate 

Syracuse University 

Kerm Henriksen, Ph.D. 

Agency for Healthcare Research and 

Quality 

Ronda G. Hughes, Ph.D., M.H.S., R.N. 

Agency for Healthcare Research and 

Quality 

Bonnie M. Jennings, D.N.Sc., R.N., 

F.A.A.N. 

Colonel, U.S. Army (Retired) and health 

care consultant 

Meg Johantgen, Ph.D., R.N. 

University of Maryland School of Nursing 

Gail M. Keenan, Ph.D., R.N. 

University of Illinois, Chicago 

Margaret A. Keyes, M.A. 

Agency for Healthcare Research and 

Quality 

Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N. 

Rush University College of Nursing, 

Chicago, IL 

Susan R. Lacey, R.N., Ph.D. 

Nursing Workforce and Systems Analysis, 

Children’s Mercy Hospitals and Clinics, 

Kansas City, MO 

Jane A. Lipscomb, Ph.D., R.N., F.A.A.N. 

University of Maryland School of Nursing 

Carol J. Loveland-Cherry, Ph.D., R.N., 

F.A.A.N. 

University of Michigan School of Nursing 

Vicki A. Lundmark, Ph.D. 

American Nurses Credentialing Center 

Courtney H. Lyder, N.D., G.N.P., F.A.A.N. 

University of Virginia 

Mary Mandeville, M.B.A. 

University of Illinois, Chicago 

Karen Dorman Marek, Ph.D., M.B.A., R.N., 

F.A.A.N. 

University of Wisconsin Milwaukee 

College of Nursing 

Diana J. Mason, R.N., Ph.D., F.A.A.N. 

American Journal of Nursing

Margo McCaffery, R.N., F.A.A.N. 

Pain management consultant 

Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., 

F.A.A.N., F.A.H.A. 

University of Washington School of 

Nursing 

Deborah F. Mulloy, M.S.N., C.N.O.R., 

Doctoral student 

University of Massachusetts at Boston 

School of Nursing 

Cindy L. Munro, R.N., A.N.P., Ph.D., 

F.A.A.N. 

Virginia Commonwealth University 

School of Nursing 

Mike R. Murphy, R.N., B.S.N., M.B.A. 

Synergy Health/St. Joseph’s Hospital 

Audrey L. Nelson, Ph.D., R.N., F.A.A.N. 

James A. Haley Veterans’ Hospital, 

Tampa, FL 

Michelle O’Daniel, M.H.A., M.S.G., 

VHA West Coast 

Eileen T. O’Grady, Ph.D., R.N., N.P. 

Nurse Practitioner World News and The 

American Journal for Nurse Practitioners

Ann E. K. Page, R.N., M.P.H. 

Institute of Medicine 

Chris Pasero, R.N. 

Pain management consultant 

Emily S. Patterson, Ph.D. 

Cincinnati VA Medical Center and Ohio 

State University 

Nirvana Huhtala Petlick 

Rutgers, The State University of New 

Jersey 

Shobha Phansalkar, R.Ph., Ph.D. 

Harvard Medical School 

xiii
Contributing Authors 

Sally Phillips, Ph.D., R.N. 

Agency for Healthcare Research and 

Quality 

Gail Powell-Cope, Ph.D., A.R.N.P., 

F.A.A.N. 

James A. Haley Veterans Hospital, 

Tampa, FL 

John Reiling, Ph.D., M.H.A., M.B.A., 

Synergy Health/St. Joseph’s Hospital 

Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N. 

Rutgers, The State University of New 

Jersey 

Victoria L. Rich, Ph.D., R.N., F.A.A.N. 

University of Pennsylvania Health System 

Ann E. Rogers, Ph.D., R.N., F.A.A.N. 

University of Pennsylvania School of 

Nursing and University of Pennsylvania 

School of Medicine 

Alan H. Rosenstein, M.D., M.B.A. 

VHA West Coast 

Linda Samia, Ph.D., R.N. 

Healthy Choices for ME, MaineHealth’s 

Partnership for Healthy Aging 

Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N. 

University of Maryland School of Nursing 

Lucy A. Savitz, Ph.D., M.B.A. 

Abt Associates 

Loretta Schlachta-Fairchild, R.N., Ph.D., 

F.A.C.H.E. 

iTelehealth Inc. 

Jean Ann Seago, Ph.D., R.N. 

School of Nursing, University of 

California, San Francisco 

Victoria L. Selby, R.N., B.S.N. 

University of Maryland School of Nursing 

Laura Senn, M.S., R.N. 

University of Minnesota School of 

Nursing 

Janis B. Smith, R.N., M.S.N. 

Children’s Mercy Hospitals and Clinics, 

Kansas City, MO 

Elizabeth S. Soule 

University of Washington School of 

Nursing 

Nancy Staggers, Ph.D., R.N., F.A.A.N. 

University of Utah College of Nursing and 

School of Medicine 

Donald Steinwachs, Ph.D. 

Johns Hopkins University 

Patricia W. Stone, Ph.D., M.P.H., R.N. 

Columbia University School of Nursing 

Molly Sutphen, Ph.D. 

Carnegie Foundation for the Advancement 

of Teaching 

Marita G. Titler, Ph.D., R.N., F.A.A.N. 

University of Iowa Hospitals and Clinics 

Alison M. Trinkoff, Sc.D., R.N., F.A.A.N. 

University of Maryland School of Nursing 

Dana Tschannen, Ph.D., R.N. 

University of Michigan. 

Mary Wakefield, Ph.D., R.N., F.A.A.N. 

University of North Dakota, Grand Forks 

Charlene Weir, Ph.D., R.N. 

VA Geriatric Research Education and 

Clinical Centers, Salt Lake City, UT 

Nancy Wells, D.N.Sc., R.N., F.A.A.N. 

Vanderbilt Medical Center and Vanderbilt 

University School of Nursing 

Susan V. White, Ph.D., R.N., C.P.H.Q., 

F.N.A.H.Q. 

James A. Haley Veterans’ Hospital, 

Tampa, FL 

Zane Robinson Wolf, Ph.D., R.N., F.A.A.N. 

La Salle University School of Nursing and 

Health Sciences 

Elizabeth Yakel, Ph.D. 

University of Michigan 

xiv
Acknowledgments 

Without a doubt, this could not have been accomplished without the contribution and 

dedication of many people, both internally and externally to the Agency for Healthcare Research 

and Quality (AHRQ). A special note of gratitude is extended to each author and peer reviewer, 

who willingly shared their expertise and dedication to making health care better and safer. This 

project would not have been possible without financial support from the Robert Wood Johnson 

Foundation and the AHRQ, as well as the time authors committed to this project. Invaluable 

support was given by Carolyn Clancy, Helen Burstin, Tonya Cooper, Susan Hassmiller, David 

Lanier, and David Meyers throughout the 2-year process of bringing this project together. 

Sincere gratitude is also extended to AHRQ’s Office of Communications and Knowledge 

Transfer (OCKT), specifically Randie Siegel (project oversight), David I. Lewin 

(copyediting/production management), and Morgan Liskinsky (marketing plan). Further 

gratitude is extended to OCKT’s editorial contractors (Helen Fox, Roslyn Rosenberg, and Daniel 

Robinson). Additional thanks go to Joy Solomita, of AHRQ’s Center for Primary Care, 

Prevenrion, and Clinical Partnerships (CP3), for all her efforts during the finalization process. 

Lastly, this book was dependent upon the invaluable assistance of Caryn McManus, Reneé 

McCullough, Lynette Lilly, and other librarians throughout the country, who helped search for 

and retrieve thousands of articles and book chapters. 

 

Ronda G. Hughes 

This book is dedicated to nurses everywhere. 

xv