AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (65)

•Identification Errors (26)

•Discontinuities, Gaps, and Hand-Off Problems (128)

•Fatigue and Sleep Deprivation (23)

•Medication Safety (255)

•Medical Complications (87)

•Nonsurgical Procedural Complications (29)

•Surgical Complications (68)

•Transfusion Complications (5)

•Psychological and Social Complications (46)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (13)

•Central and South America (2)

•Europe (57)

•North America (820)

Resource Types
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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (49)

•Active Errors (196)

•Latent Errors (108)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (269)

•Legal and Policy Approaches (180)

•Error Reporting and Analysis (263)

•Communication Improvement (264)

•Human Factors Engineering (134)

•Teamwork (75)

•Specialization of Care (75)

•Logistical Approaches (71)

•Culture of Safety (157)

•Technologic Approaches (177)

•Education and Training (216)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (764)

•Health Care Executives and Administrators (727)

•Non-Health Care Professionals (394)

•Patients (40)

Setting of Care

•Hospitals (612)

•Psychiatric Facilities (4)

•Residential Facilities (10)

•Ambulatory Care (99)

•Outpatient Surgery (6)

•Patient Transport (2)

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COMMENTARY

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

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

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

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

COMMENTARY

Simple strategies to avoid medication errors.

Jenkins RH, Vaida AJ. Fam Pract Manag. 2007;14:41-47.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.

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.

COMMENTARY

Medication reconciliation campaign in a clinic for homeless patients.

Moczygemba LR, Gatewood SB, Kennedy AK, et al. Am J Health Syst Pharm. 2012;69:558-562.

COMMENTARY

Safer out of hours primary care.

Cosford PA, Thomas JM. BMJ. 2010;340:c3194.

COMMENTARY

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. Jt Comm J Qual Patient Saf. 2006;32:299-308.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

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

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

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

Implementing a team-based daily goals sheet in a non-ICU setting.

Holzmueller CG, Timmel J, Kent PS, Schulick RD, Pronovost PJ. Jt Comm J Qual Patient Saf. 2009;35:384-388.

COMMENTARY classic

Healthcare in a land called PeoplePower: nothing about me without me.

Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-150.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

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