AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (47)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (98)

•Fatigue and Sleep Deprivation (24)

•Medication Safety (168)

•Medical Complications (44)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (82)

•Transfusion Complications (2)

•Psychological and Social Complications (21)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (6)

•Europe (22)

•North America (672)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (27)

•Active Errors (154)

•Latent Errors (66)

•Near Miss (13)

Approach to Improving Safety

•Quality Improvement Strategies (187)

•Legal and Policy Approaches (55)

•Error Reporting and Analysis (149)

•Communication Improvement (234)

•Human Factors Engineering (123)

•Teamwork (105)

•Specialization of Care (55)

•Logistical Approaches (56)

•Culture of Safety (114)

•Technologic Approaches (104)

•Education and Training (249)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (584)

•Health Care Executives and Administrators (622)

•Non-Health Care Professionals (296)

•Patients (9)

Setting of Care

•Hospitals (445)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (44)

•Outpatient Surgery (4)

•Patient Transport (5)

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COMMENTARY

Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.

Gosbee J. Clin Obstet Gynecol. 2010;53:545-558.

COMMENTARY

Toward a definition of teamwork in emergency medicine.

Fernandez R, Kozlowski SWJ, Shapiro MJ, Salas E. Acad Emerg Med. 2008;15:1104-1112.

COMMENTARY

Identified safety risks with splitting and crushing oral medications.

Paparella S. J Emerg Nurs. 2010;36:156-158.

COMMENTARY

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

McKeon LM, Oswaks JD, Cunningham PD. Clin Nurse Spec. 2006;20:298-304 (CE Test 305-306).

COMMENTARY

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 Institute of Medicine resident duty hours recommendations.

Wagner MJ, Wolf S, Promes S, et al. J Emerg Med. 2010;39:348-355.

COMMENTARY

Bedside shift report improves patient safety and nurse accountability.

Baker SJ. J Emerg Nurs. 2010;36:355-358.

COMMENTARY

A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.

Chesluk BJ, Bernabeo E, Hess B, Lynn LA, Reddy S, Holmboe ES. Health Aff (Millwood). 2012;31:2485-2492.

COMMENTARY

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. J Patient Saf. 2009;5:184-187.

COMMENTARY

Do not put medication safety "on hold" with boarded patients.

Paparella S. J Emerg Nurs. 2010;36:347-349.

COMMENTARY

Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system.

Deering S, Rosen MA, Salas E, King HB. Simul Healthc. 2009;4:166-173.

COMMENTARY

Improving patient safety: patient-focused, high-reliability team training.

McKeon LM, Cunningham PD, Detty Oswaks JS. J Nurs Care Qual. 2009;24:76-82.

COMMENTARY

Portable advanced medical simulation for new emergency department testing and orientation.

Kobayashi L, Shapiro MJ, Sucov A, et al. Acad Emerg Med. 2006;13:691-695.

COMMENTARY

Twelve best practices for team training evaluation in health care.

Weaver SJ, Salas E, King HB. Jt Comm J Qual Patient Saf. 2011;37:341-349.

COMMENTARY

Patient safety and collaboration of the intensive care unit team.

Despins LA. Crit Care Nurse. April 2009;29:85-91.

COMMENTARY

Pediatric medication safety in the emergency department.

Cadwell SM. J Emerg Nurs. 2008;34:375-377.

COMMENTARY

Lessons learned: basic evidence-based advice for preventing medication errors in children.

Thomas DO. J Emerg Nurs. 2005;31:490-493.

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

COMMENTARY

Improving patient safety with team coordination: challenges and strategies of implementation.

Harris KT, Treanor CM, Salisbury ML. J Obset Gynol Neonatal Nurs. 2006;35:557-566.

COMMENTARY

Emergency medicine quality improvement and patient safety curriculum.

Kelly JJ, Thallner E, Broida RI, et al. Acad Emerg Med. 2010;17(suppl 2):e110-e129.

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