AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (46)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (59)

•Fatigue and Sleep Deprivation (14)

•Medication Safety (148)

•Medical Complications (49)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (68)

•Transfusion Complications (3)

•Psychological and Social Complications (24)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (7)

•Central and South America (1)

•Europe (23)

•North America (639)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (26)

•Active Errors (121)

•Latent Errors (55)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (180)

•Legal and Policy Approaches (76)

•Error Reporting and Analysis (195)

•Communication Improvement (176)

•Human Factors Engineering (115)

•Teamwork (67)

•Specialization of Care (47)

•Logistical Approaches (46)

•Culture of Safety (107)

•Technologic Approaches (107)

•Education and Training (149)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (597)

•Health Care Executives and Administrators (593)

•Non-Health Care Professionals (250)

•Patients (21)

Setting of Care

•Hospitals (366)

•Residential Facilities (4)

•Ambulatory Care (49)

•Outpatient Surgery (7)

•Patient Transport (3)

1 - 20 of 693

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COMMENTARY

Radiology failure mode and effect analysis: what is it?

Abujudeh HH, Kaewlai R. Radiology. 2009;252:544-550.

COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

COMMENTARY

Patient safety event reporting in a large radiology department.

Schultz SR, Watson RE Jr, Prescott SL, et al. AJR Am J Roentgenol. 2011;197:684-688.

COMMENTARY

Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology.

Sidhu M, Goske MJ, Connolly B, et al. AJR Am J Roentgenol. 2010;195:W299-W301.

COMMENTARY

Rethinking peer review: what aviation can teach radiology about performance improvement.

Larson DB, Nance JJ. Radiology. 2011;259:626-632.

COMMENTARY

Improving patient safety in radiology: concepts for a comprehensive patient safety program.

Donnelly LF, Dickerson JM, Goodfriend MA, Muething SE. Semin Ultrasound CT MRI. 2010;31:67-70.

COMMENTARY

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

COMMENTARY

Random safety auditing, root cause analysis, failure mode and effects analysis.

Ursprung R, Gray J. Clin Perinatol. 2010;37:141-165.

COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

COMMENTARY

Quality initiatives: developing a radiology quality and safety program: a primer.

Johnson CD, Krecke KN, Roberts RM, Denham C. Radiographics. 2009;29:951-959.

COMMENTARY

Anatomy and pathophysiology of errors occurring in clinical radiology practice.

Brook OR, O'Connell AM, Thornton E, Eisenberg RL, Mendiratta-Lala M, Kruskal JB. Radiographics. 2010;30:1401-1410.

COMMENTARY

Improving patient safety in radiation oncology.

Hendee WR, Herman MG. Med Phys. 2011;38:78-82.

COMMENTARY

Beyond the prescription: medication monitoring and adverse drug events in older adults.

Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc. 2011;59:1513-1520.

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

A pediatric medical emergency team manages a complex child with hypoxia and a worried parent.

Shilkofski NA, Hunt EA. Jt Comm J Qual Patient Saf. 2007;33:236-241.

COMMENTARY classic

Effectiveness and efficiency of root cause analysis in medicine.

Wu AW, Lipshutz AKM, Pronovost PJ. JAMA. 2008;299:685-687.

COMMENTARY

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

Lubomski LH, Marsteller JA, Hsu YJ, et al. Jt Comm J Qual Patient Saf. 2008;34:619-623.

COMMENTARY

Time out for patient safety.

Meginniss A, Damian F, Falvo F. J Emerg Nurs. 2012;38:51-53.

COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

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