AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (51)

•Diagnostic Errors (42)

•Identification Errors (16)

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

•Fatigue and Sleep Deprivation (21)

•Medication Safety (164)

•Medical Complications (88)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (59)

•Transfusion Complications (5)

•Psychological and Social Complications (33)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (9)

•Central and South America (1)

•Europe (48)

•North America (724)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (35)

•Active Errors (143)

•Latent Errors (96)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (260)

•Legal and Policy Approaches (141)

•Error Reporting and Analysis (220)

•Communication Improvement (209)

•Human Factors Engineering (152)

•Teamwork (83)

•Specialization of Care (71)

•Logistical Approaches (59)

•Culture of Safety (259)

•Technologic Approaches (140)

•Education and Training (199)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (583)

•Health Care Executives and Administrators (724)

•Non-Health Care Professionals (371)

•Patients (23)

Setting of Care

•Hospitals (563)

•Psychiatric Facilities (2)

•Residential Facilities (9)

•Ambulatory Care (56)

•Outpatient Surgery (3)

•Patient Transport (2)

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COMMENTARY

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

COMMENTARY

Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges.

Murray E, Holmes A. J Antimicrob Chemother. 2012;67(suppl 1):i29-i36.

COMMENTARY

As she lay dying: how I fought to stop medical errors from killing my mom.

Welch JR. Health Aff (Millwood). 2012;31:2817-2820.

COMMENTARY

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

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

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

COMMENTARY

A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.

Scott C, Gerardi D. Jt Comm J Qual Patient Saf. 2011;37:59-69, 70-80.

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

Physicians with multiple patient complaints: ending our silence.

Gallagher TH, Levinson W. BMJ Qual Saf. 2013 Apr 18; [Epub ahead of print].

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

Integrating CUSP and TRIP to improve patient safety.

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

COMMENTARY

Using a logic model to design and evaluate quality and patient safety improvement programs.

Goeschel CA, Weiss WM, Pronovost PJ. Int J Qual Health Care. 2012;24:330-337.

COMMENTARY

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.

Pryor D, Hendrich A, Henkel RJ, Beckmann JK, Tersigni AR. Health Aff (Millwood). 2011;30:604-611.

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

How to develop a second victim support program: a toolkit for health care organizations.

Pratt S, Kenney L, Scott SD, Wu AW. Jt Comm J Qual Patient Saf. 2012;38:235-240.

COMMENTARY

Nosocomial infection, the Deficit Reduction Act, and incentives for hospitals.

Graves N, McGowan JE Jr. JAMA. 2008;300:1577-1579.

COMMENTARY

Leading a highly visible hospital through a serious reportable event.

Erickson JI. J Nurs Adm. 2012;42:131-133.

COMMENTARY

Perspective: a culture of respect—part 1 and part 2.

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012;87:845-858.

COMMENTARY

High reliability: truly achieving healthcare quality and safety.

Blouin AS. Front Health Serv Manage. 2013;29:35-40.

COMMENTARY

Moving beyond readmission penalties: creating an ideal process to improve transitional care.

Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. J Hosp Med. 2013;8:102-109.

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