AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (44)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (87)

•Fatigue and Sleep Deprivation (14)

•Medication Safety (223)

•Medical Complications (55)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (69)

•Transfusion Complications (5)

•Psychological and Social Complications (28)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (8)

•Central and South America (1)

•Europe (29)

•North America (723)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (31)

•Active Errors (150)

•Latent Errors (75)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (209)

•Legal and Policy Approaches (97)

•Error Reporting and Analysis (202)

•Communication Improvement (214)

•Human Factors Engineering (136)

•Teamwork (67)

•Specialization of Care (61)

•Logistical Approaches (57)

•Culture of Safety (114)

•Technologic Approaches (197)

•Education and Training (172)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (671)

•Health Care Executives and Administrators (657)

•Non-Health Care Professionals (322)

•Patients (28)

Setting of Care

•Hospitals (417)

•Psychiatric Facilities (2)

•Residential Facilities (9)

•Ambulatory Care (68)

•Outpatient Surgery (7)

•Patient Transport (2)

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COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists.

Wakefield DS, Ward MM, Loes JL, O'Brien J, Sperry L. Am J Health Syst Pharm. 2010;67:2052-2057.

COMMENTARY

Medication Reconciliation Victory after an Avoidable Error

Cutler TW. AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

Incomplete care—on the trail of flaws in the system.

Gandhi TK, Zuccotti G, Lee TH. N Engl J Med. 2011;365:486-488.

COMMENTARY

Can electronic clinical documentation help prevent diagnostic errors?

Schiff GD, Bates DW. N Engl J Med. 2010;362:1066-1069.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

COMMENTARY

EMR Entry Error: Not So Benign

Koppel R. AHRQ WebM&M [serial online]. April 2009.

COMMENTARY

Detecting adverse drug events through data mining.

Glasgow JM, Kaboli PJ. Am J Health Syst Pharm. 2010;67:317-320.

COMMENTARY

The Triangle Model for evaluating the effect of health information technology on healthcare quality and safety.

Ancker JS, Kern LM, Abramson E, Kaushal R. J Am Med Inform Assoc. 2012;19:61-65.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

COMMENTARY

Comprehensive analysis of a medication dosing error related to CPOE.

Horsky J, Kuperman GJ, Patel VL. J Am Med Inform Assoc. 2005;12:377-382.

COMMENTARY

ISMP medication error report analysis.

Cohen M. Hosp Pharm. 2006;41:222-224.

COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

COMMENTARY

Responding to large-scale testing errors.

Valenstein PN, Alpern GA, Keren DF. Am J Clin Pathol. 2010;133:440-446.

COMMENTARY

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.

Scott IA, Gray LC, Martin JH, Mitchell CA. Am J Med. 2012;125:529-537.e4.

COMMENTARY classic

Errors in laboratory medicine: practical lessons to improve patient safety.

Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.

Bernstein J, MacCourt DC, Jacob DM, Mehta S. Clin Orthop Relat Res. 2010;468:2627-2732.

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