AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (7)

•Diagnostic Errors (15)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (41)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (59)

•Medical Complications (21)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (30)

•Transfusion Complications (2)

•Psychological and Social Complications (29)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (32)

•Europe (38)

•North America (234)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (12)

•Active Errors (56)

•Latent Errors (40)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (110)

•Legal and Policy Approaches (89)

•Error Reporting and Analysis (152)

•Communication Improvement (113)

•Human Factors Engineering (43)

•Teamwork (46)

•Specialization of Care (21)

•Logistical Approaches (24)

•Culture of Safety (99)

•Technologic Approaches (44)

•Education and Training (75)

Clinical Areas

•Allied Health Services (3)

•Medicine (167)

•Nursing (19)

•Pharmacy (25)

Target Audience

•Health Care Providers (319)

•Health Care Executives and Administrators (354)

•Non-Health Care Professionals (215)

•Patients (20)

Setting of Care

•Hospitals (173)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (11)

•Outpatient Surgery (2)

•Patient Transport (2)

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COMMENTARY

A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

Iedema RA, Jorm C, Braithwaite J, Travaglia J, Lum M. Soc Sci Med. 2006;63:1201-1212.

COMMENTARY

Culture, language, and patient safety: making the link.

Johnstone MJ, Kanitsaki O. Int J Qual Health Care. 2006;18:383-8.

COMMENTARY

Practising open disclosure: clinical incident communication and systems improvement.

Iedema R, Jorm C, Wakefield J, Ryan C, Dunn S. Sociol Health Illn. 2009;31:262-77.

COMMENTARY

In the wake of hospital inquiries: impact on staff and safety.

Dunbar JA, Reddy P, Beresford B, Ramsey WP, Lord RS. Med J Aust. 2007;186:80-83.

COMMENTARY

Disclosing harmful medical errors to patients: tackling three tough cases.

Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Chest. 2009;136:897-903.

COMMENTARY

Disclosing medical errors to patients: a challenge for health care professionals and institutions.

Levinson W. Patient Educ Couns. 2009;76:296-299.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

COMMENTARY

An alternative to the clinical negligence system.

Furniss R, Ormond-Walshe S. BMJ. 2007;334:400-402.

COMMENTARY

Disclosing harmful medical errors to patients: a time for professional action.

Gallagher TH, Levinson W. Arch Intern Med. 2005;165:1819-1824.

COMMENTARY

In Conversation with...David Marx, JD

AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Drill down with root cause analysis.

McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.

COMMENTARY

How does the law recognize and deal with medical errors?

Merry AF. J R Soc Med. 2009;102:265-271.

COMMENTARY

Creating a fair and just culture: one institution's path toward organizational change.

Connor M, Duncombe D, Barclay E, et al. Jt Comm J Qual Patient Saf. 2007;33:617-624.

COMMENTARY

Transfer of accountability: transforming shift handover to enhance patient safety.

Alvarado K, Lee R, Christoffersen E, et al. Healthc Q. 2006;9(special issue):75-79.

COMMENTARY

Improving hospital performance: culture change is not the answer.

Leggat SG, Dwyer J. Healthc Q. 2005;8:60-68.

COMMENTARY

In Conversation with…Jack Barker, PhD

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

COMMENTARY

Developing a national patient safety education framework for Australia.

Walton MM, Shaw T, Barnet S, Ross J. Qual Saf Health Care. 2006;15:437-442.

COMMENTARY

In Conversation with…Thomas H. Gallagher, MD

AHRQ WebM&M [serial online]. January 2009.

COMMENTARY

In Conversation with...Allan Frankel, MD

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

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

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