AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (51)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (166)

•Fatigue and Sleep Deprivation (32)

•Medication Safety (198)

•Medical Complications (71)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (68)

•Transfusion Complications (5)

•Psychological and Social Complications (35)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (15)

•Central and South America (2)

•Europe (48)

•North America (764)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (40)

•Active Errors (168)

•Latent Errors (99)

•Near Miss (16)

Approach to Improving Safety

•Quality Improvement Strategies (241)

•Legal and Policy Approaches (100)

•Error Reporting and Analysis (198)

•Communication Improvement (242)

•Human Factors Engineering (152)

•Teamwork (79)

•Specialization of Care (76)

•Logistical Approaches (82)

•Culture of Safety (135)

•Technologic Approaches (197)

•Education and Training (207)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (615)

•Health Care Executives and Administrators (737)

•Non-Health Care Professionals (411)

•Patients (13)

Setting of Care

•Hospitals (601)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (72)

•Outpatient Surgery (4)

•Patient Transport (5)

1 - 20 of 895

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COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.

Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I. Acad Med. 2012;87:411-418.

COMMENTARY

Mitigating error vulnerability at the transition of care through the use of health IT applications.

Cortelyou-Ward K, Swain A, Yeung T. J Med Syst. 2012;36:3825-3831.

COMMENTARY

Ticket to ride: reducing handoff risk during hospital patient transport.

Pesanka DA, Greenhouse PK, Rack LL, et al. J Nurs Care Qual. 2009;24:109-115.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

COMMENTARY

Implementing AORN recommended practices for transfer of patient care information.

Seifert PC. AORN J. 2012;96:475-493.

COMMENTARY

A theoretical framework and competency-based approach to improving handoffs.

Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. Qual Saf Health Care. 2008;17:11-14.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

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

Implementing handoff communication.

Ardoin KB, Broussard L. J Nurses Staff Dev. 2011;27:128-135.

COMMENTARY

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.

Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

COMMENTARY

Implementing a perioperative handoff tool to improve postprocedural patient transfers.

Petrovic MA, Martinez EA, Aboumatar H. Jt Comm J Qual Patient Saf. 2012;38:135-142.

COMMENTARY

Complementary telephone strategies to improve postdischarge communication.

Rennke S, Kesh S, Neeman N, Sehgal NL. Am J Med. 2012;125:28-30.

COMMENTARY

Blending evidence and innovation: improving intershift handoffs in a multihospital setting.

Thomas L, Donohue-Porter P. J Nurs Care Qual. 2012;27:116-124.

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