AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (50)

•Diagnostic Errors (43)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (153)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (220)

•Medical Complications (69)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (74)

•Transfusion Complications (5)

•Psychological and Social Complications (34)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (13)

•Central and South America (1)

•Europe (25)

•North America (775)

Resource Types
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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (41)

•Active Errors (168)

•Latent Errors (95)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (229)

•Legal and Policy Approaches (79)

•Error Reporting and Analysis (190)

•Communication Improvement (251)

•Human Factors Engineering (150)

•Teamwork (90)

•Specialization of Care (84)

•Logistical Approaches (77)

•Culture of Safety (135)

•Technologic Approaches (141)

•Education and Training (212)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (675)

•Health Care Executives and Administrators (756)

•Non-Health Care Professionals (291)

•Patients (13)

Setting of Care

•Hospitals (601)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (62)

•Outpatient Surgery (6)

•Patient Transport (6)

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COMMENTARY

Clinical nurse specialists as leaders in rapid response.

Jenkins SD, Lindsey PL. Clin Nurse Spec. 2010;24:24-30.

COMMENTARY

Development of a modified early warning score using the electronic medical record.

Albert BL, Huesman L. Dimens Crit Care Nurs. 2011;30:283-292.

COMMENTARY

Using an advanced practice nursing model for a rapid response team.

Benson L, Mitchell C, Link M, Carlson G, Fisher J. Jt Comm J Qual Patient Saf. 2008;34:743-747.

COMMENTARY

Rolling out the rapid response team.

Gallagher-Ford L, Fineout-Overholt E, Melnyk BM, Stillwell SB. Am J Nurs. 2011;111:42-47.

COMMENTARY

Bringing change-of-shift report to the bedside: a patient- and family-centered approach.

Griffin T. J Perinat Neonatal Nurs. 2010;24:348-353.

COMMENTARY

Strategies for improving patient safety: linking task type to error type.

Mattox EA. Crit Care Nurse. 2012;32:52-78.

COMMENTARY

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

Tessier EG, Henneman EA, Nathanson B, Plotkin K, Heelon M. Am J Health Syst Pharm. 2010;67:607-611.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

COMMENTARY

A plan for achieving significant improvement in patient safety.

Johnson K, Maultsby CC. J Nurs Care Qual. 2007;22:164-171.

COMMENTARY

Noise: a distraction, interruption, and safety hazard.

Beyea SC. AORN J. 2007;86:281, 283-285.

COMMENTARY

Blending evidence and innovation: improving intershift handoffs in a multihospital setting.

Thomas L, Donohue-Porter P. J Nurs Care Qual. 2012;27:116-124.

COMMENTARY

CPOE: strategies for success.

Manor PJ. Nurs Manage. 2010;41:18-20.

COMMENTARY

Revitalizing an established rapid response team.

Genardi ME, Cronin SN, Thomas L. Dimens Crit Care Nurs. 2008;27:104-109.

COMMENTARY

Ticket to ride: reducing handoff risk during hospital patient transport.

Pesanka DA, Greenhouse PK, Rack LL, et al. J Nurs Care Qual. 2009;24:109-115.

COMMENTARY

Implementing AORN recommended practices for medication safety.

Hicks RW, Wanzer LJ, Denholm B. AORN J. 2012;96:605-622.

COMMENTARY

Implementing a rapid response team: a practical guide.

Garretson S, Dip HE, Rauzi MB. Nursing. 2008;38:56cc1-56cc3.

COMMENTARY

Rapid response systems: from implementation to evidence base.

Sarani B, Scott S. Jt Comm J Qual Patient Saf. 2010;36:514-517.

COMMENTARY

A performance improvement plan to increase nurse adherence to use of medication safety software.

Gavriloff C. J Pediatr Nurs. 2012;27:375-382.

COMMENTARY

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

Thornlow DK, Anderson R, Oddone E. Int J Nurs Stud. 2009;46:1528-1535.

COMMENTARY

Implementing a safe and reliable process for medication administration.

Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.

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