AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (41)

•Identification Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (108)

•Fatigue and Sleep Deprivation (25)

•Medication Safety (174)

•Medical Complications (75)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (51)

•Transfusion Complications (4)

•Psychological and Social Complications (37)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (15)

•Central and South America (2)

•Europe (52)

•North America (765)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (40)

•Active Errors (146)

•Latent Errors (143)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (253)

•Legal and Policy Approaches (173)

•Error Reporting and Analysis (257)

•Communication Improvement (215)

•Human Factors Engineering (115)

•Teamwork (96)

•Specialization of Care (73)

•Logistical Approaches (69)

•Culture of Safety (269)

•Technologic Approaches (147)

•Education and Training (248)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (614)

•Health Care Executives and Administrators (771)

•Non-Health Care Professionals (482)

•Patients (24)

Setting of Care

•Hospitals (558)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (51)

•Outpatient Surgery (3)

•Patient Transport (2)

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COMMENTARY classic

Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.

Gaba DM. Calif Manage Rev. 2000;43:1-20.

COMMENTARY classic

Organizational culture as a source of high reliability.

Weick KE. Calif Manage Rev. 1987;29:112-127.

COMMENTARY

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

Apold J, Quigley PA. J Nurs Care Qual. 2012;27:299-306.

COMMENTARY

The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.

Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.

COMMENTARY

Duty hour reform in a shifting medical landscape.

Jena AB, Prasad V. J Gen Intern Med. 2013 Apr 9; [Epub ahead of print].

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Frontline hospital workers and the worker safety/patient safety nexus.

Sokas R, Braun B, Chenven L, et al. Jt Comm J Qual Patient Saf. 2013;39:185-192.

COMMENTARY classic

The new recommendations on duty hours from the ACGME Task Force.

Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.

COMMENTARY

Electronic health records and National Patient-Safety Goals.

Sittig DF, Singh H. N Engl J Med. 2012;367:1854-1860.

COMMENTARY

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

Guralnick S, Rushton J, Bale JF Jr, Norwood V, Trimm F, Schumacher D. Pediatrics. 2010;125:786-790.

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

COMMENTARY

In Conversation with...Lucian Leape, MD

AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

Integrating CUSP and TRIP to improve patient safety.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.

COMMENTARY

Development and implementation of a hospital-based patient safety program.

Frush KS, Alton M, Frush DP. Pediatr Radiol. 2006;36:291-298.

COMMENTARY

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Kavanagh KT. Soc Work Public Health. 2011;26:524-541.

COMMENTARY

"Health courts" and accountability for patient safety.

Mello MM, Studdert DM, Kachalia AB, Brennan TA. Milbank Q. 2006;84:459-492.

COMMENTARY

Residents' duty hours—toward an empirical narrative.

Rosenbaum L, Lamas D. N Engl J Med. 2012;367:2044-2049.

COMMENTARY

CMS changes in reimbursement for HAIs: setting a research agenda.

Stone PW, Glied SA, McNair PD, et al. Med Care. 2010;48:433-439.

COMMENTARY

Getting moving on patient safety—harnessing electronic data for safer care.

Jha AK, Classen DC. N Engl J Med 2011;365:1756-1758.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

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