AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (8)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (23)

•Medical Complications (7)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (10)

•Psychological and Social Complications (1)

Origin/Sponsor

•Europe (3)

•North America (57)

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Organizational Policy/Guidelines

Error Types

•Epidemiology of Errors and Adverse Events (3)

•Active Errors (5)

•Latent Errors (4)

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (6)

•Error Reporting and Analysis (6)

•Communication Improvement (16)

•Human Factors Engineering (13)

•Teamwork (3)

•Specialization of Care (4)

•Logistical Approaches (2)

•Culture of Safety (5)

•Technologic Approaches (12)

•Education and Training (8)

Clinical Areas

•Medicine (43)

•Nursing (3)

•Pharmacy (11)

Target Audience

•Health Care Providers (57)

•Health Care Executives and Administrators (45)

•Non-Health Care Professionals (13)

•Patients (1)

Setting of Care

•Hospitals (33)

•Residential Facilities (1)

•Ambulatory Care (8)

•Outpatient Surgery (3)

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ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #398: fatigue and patient safety.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2008;111:471-474.

ORGANIZATIONAL POLICY/GUIDELINES

American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards.

Jacobson JO, Polovich M, McNiff KK, et al; American Society of Clinical Oncology; Oncology Nursing Society. Oncol Nurs Forum. 2009;36:651-658.

ORGANIZATIONAL POLICY/GUIDELINES

Joint Policy Statement—Guidelines for Care of Children in the Emergency Department.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2009;124:1233-1243.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #367: communication strategies for patient handoffs.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2007;109:1503-1505.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #472: patient safety and the electronic health record.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:1245-1247.

ORGANIZATIONAL POLICY/GUIDELINES

Safety considerations for IMRT.

Moran JM, Dempsey M, Eisbruch A, et al. Pract Radiat Oncol. 2011;1(suppl 1):1-33.

ORGANIZATIONAL POLICY/GUIDELINES

ASHP guidelines on the safe use of automated dispensing devices.

Am J Health Syst Pharm. 2010;67:483-490.

ORGANIZATIONAL POLICY/GUIDELINES

Practice advisory for the prevention and management of operating room fires.

Caplan RA, Barker SJ, Connis RT, et al; for American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2008;108:786-801.

ORGANIZATIONAL POLICY/GUIDELINES

Radiation risks of diagnostic imaging.

Sentinel Event Alert #47. August 24, 2011.

ORGANIZATIONAL POLICY/GUIDELINES

ASHP guidelines on remote medication order processing.

Thompson B, Conrad G, Gum MO, et al; ASHP Expert Panel on Remote Medication Order Processing. Am J Health Syst Pharm. 2010;67:672-677.

ORGANIZATIONAL POLICY/GUIDELINES

Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum.

Nutescu EA, Wittkowsky AK, Burnett A, Merli GJ, Ansell JE, Garcia DA. Ann Pharmacother. 2013;47:714-724.

ORGANIZATIONAL POLICY/GUIDELINES classic

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee opinion #531: improving medication safety.

ACOG Committee on Patient Safety and Quality Improvement of American College of Obstetricians-Gynecologists. Obstet Gynecol. 2012;120:406-410.

ORGANIZATIONAL POLICY/GUIDELINES

EACTS guidelines for the use of patient safety checklists.

Clark SC, Dunning J, Alfieri OR, et al; Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg. 2012;41:993-1004.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

ORGANIZATIONAL POLICY/GUIDELINES

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.

AORN J. 2006;84:276-278, 280-283.

ORGANIZATIONAL POLICY/GUIDELINES

Using medication reconciliation to prevent errors.

Sentinel Event Alert. January 25, 2006;(35):1-4.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

ORGANIZATIONAL POLICY/GUIDELINES

Medical device alarm safety in hospitals.

Sentinel Event Alert. April 8, 2013;(50):1-3.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

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