AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (22)

•Diagnostic Errors (37)

•Identification Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (95)

•Medical Complications (35)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (56)

•Transfusion Complications (2)

•Psychological and Social Complications (56)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (15)

•Europe (28)

•North America (588)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (24)

•Active Errors (74)

•Latent Errors (56)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (190)

•Legal and Policy Approaches (127)

•Error Reporting and Analysis (237)

•Communication Improvement (143)

•Human Factors Engineering (65)

•Teamwork (72)

•Specialization of Care (32)

•Logistical Approaches (41)

•Culture of Safety (166)

•Technologic Approaches (94)

•Education and Training (139)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (447)

•Health Care Executives and Administrators (555)

•Non-Health Care Professionals (336)

•Patients (21)

Setting of Care

•Hospitals (288)

•Residential Facilities (3)

•Ambulatory Care (40)

•Outpatient Surgery (2)

•Patient Transport (1)

1 - 20 of 671

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COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

COMMENTARY

Using the Communication and Teamwork Skills (CATS) assessment to measure health care team performance.

Frankel A, Gardner R, Maynard L, Kelly A. Jt Comm J Qual Patient Saf. 2007;33:549-558.

COMMENTARY

Event reporting: the value of a nonpunitive approach.

Youngberg BJ. Clin Obstet Gynecol. 2008;51:647-655.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

COMMENTARY

Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department.

Bradley Morrison J, Rudolph JW. Acad Emerg Med. 2011;18:1246-1254.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

COMMENTARY

Disruptive clinician behavior: a persistent threat to patient safety.

Porto G, Lauve R. Patient Safety Qual Healthc. July/August 2006;3:16-24.

COMMENTARY

Ambiguity and workarounds as contributors to medical error.

Spear SJ, Schmidhofer M. Ann Intern Med. 2005;142:627-630.

COMMENTARY

'Some worms are best left in the can'—should you hide medical errors?

Weiss GG. Medscape Med Ethics [serial online]. January 4, 2011.

COMMENTARY classic

Problem doctors: is there a system-level solution?

Leape LL, Fromson JA. Ann Intern Med. 2006;144:107-115.

COMMENTARY

Medical error, incident investigation and the second victim: doing better but feeling worse?

Wu AW, Steckelberg RC. BMJ Qual Saf. 2012;21:267-270.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Aging gracefully? Patient safety advocates call for ongoing skills assessments for older physicians.

McKenna M. Ann Emerg Med. 2011;58:A15-A17.

COMMENTARY

A case of the birth and death of a high reliability healthcare organisation.

Roberts KH, Madsen P, Desai V, Van Stralen D. Qual Saf Health Care. 2005;14:216-220.

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

Clinical care checklists: salvations or frustrations?

Jones JW, McCullough LB. J Vasc Surg. 2011;53:1429-1430.

COMMENTARY

Monitoring patient safety in health care: building the case for surrogate measures.

Gaynes RP, Platt R. Jt Comm J Qual Patient Saf. 2006;32:95-101.

COMMENTARY

Improving rapid response systems: progress, issues, and future directions.

Øvretveit J, Suffoletto J. Jt Comm J Qual Patient Saf. 2007;33:512-519.

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

COMMENTARY

The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.

Patel P, Robinson BS, Novicoff WM, Dunnington GL, Brenner MJ, Saleh KJ. J Bone Joint Surg Am. 2011;93:e1261-e1266.

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