AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (15)

•Diagnostic Errors (11)

•Identification Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (19)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (45)

•Medical Complications (27)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (18)

•Transfusion Complications (2)

•Psychological and Social Complications (10)

Origin/Sponsor

•Australia and New Zealand (1)

•Europe (3)

•North America (332)

Resource Types
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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (7)

•Active Errors (30)

•Latent Errors (26)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (108)

•Legal and Policy Approaches (73)

•Error Reporting and Analysis (101)

•Communication Improvement (48)

•Human Factors Engineering (36)

•Teamwork (28)

•Specialization of Care (25)

•Logistical Approaches (21)

•Culture of Safety (100)

•Technologic Approaches (56)

•Education and Training (60)

Clinical Areas

•Allied Health Services (1)

•Medicine (147)

•Nursing (13)

•Pharmacy (25)

Target Audience

•Health Care Providers (191)

•Health Care Executives and Administrators (335)

•Non-Health Care Professionals (178)

•Patients (12)

Setting of Care

•Hospitals (152)

•Residential Facilities (3)

•Ambulatory Care (13)

•Outpatient Surgery (1)

1 - 20 of 337

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COMMENTARY

Is yours a learning organization?

Garvin DA, Edmondson AC, Gino F. Harv Bus Rev. 2008;86:109-116.

COMMENTARY

Creating complex health improvement programs as mindful organizations: from theory to action.

Issel LM, Narasimha KM. J Health Organ Manag. 2007;21:166-183.

COMMENTARY

Creating a safer health care system: finding the constraint.

Pauker SG, Zane EM, Salem DN. JAMA. 2005;294:2906-2908.

COMMENTARY

Patient Safety Organizations: a new paradigm in quality management and communication systems in healthcare.

Dotan DB. J Clin Eng. 2009;34:142-146.

COMMENTARY

Event reporting: the value of a nonpunitive approach.

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

COMMENTARY

The Safe Tables Collaborative: a statewide experience.

Wagner CA, Cecchettini D, Fletcher J. Jt Comm J Qual Patient Saf. 2011;37:206-210.

COMMENTARY

Seeing systems in health care organizations.

Friedman LH, King JB, Bella D. Physician Exec. Jul-Aug 2007;33:20-29.

COMMENTARY

The competitive imperative of learning.

Edmondson AC. Harv Bus Rev. 2008;86:60-67, 160.

COMMENTARY

Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.

Sorensen AV, Bernard SL. Jt Comm J Qual Patient Saf. 2012;38:89-95.

COMMENTARY

Pharmacist involvement in a rapid-response team at a community hospital.

Cooper BE. Am J Health Syst Pharm. 2007;64:694, 697-698.

COMMENTARY

Safety leadership: managing the paradox.

Carrillo RA. Prof Safety. July 2005;50:31-34.

COMMENTARY

Interdisciplinary team training: five lessons learned.

Contratti F, Ng G, Deeb J. Am J Nurs. 2012;112:47-52.

COMMENTARY

Reducing medical error in the Military Health System: how can team training help?

Alonso A, Baker DP, Holtzman A, et al. Hum Resource Manage Rev. 2006;16:396-415.

COMMENTARY

Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery.

Grady MS, Batjer HH, Dacey RG. J Neurosurg. 2009;110:828-836.

COMMENTARY

Scientific inquiry. 100,000 lives campaign and the application to children.

Edson BS, Williams MC. J Spec Pediatr Nurs. 2006;11:138-142.

COMMENTARY

The WHO World Alliance for Patient Safety: a new challenge or an old one neglected?

Edwards IR. Drug Saf. 2005;28:379-386.

COMMENTARY

Why the nation needs a policy push on patient-centered health care.

Epstein RM, Fiscella K, Lesser CS, Stange KC. Health Aff (Millwood). 2010;29:1489-1495.

COMMENTARY

Disclosing harmful medical errors to patients: a time for professional action.

Gallagher TH, Levinson W. Arch Intern Med. 2005;165:1819-1824.

COMMENTARY

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Jt Comm J Qual Patient Saf. 2010;36:519-524.

COMMENTARY

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

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

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