AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (39)

•Identification Errors (11)

•Discontinuities, Gaps, and Hand-Off Problems (89)

•Fatigue and Sleep Deprivation (21)

•Medication Safety (180)

•Medical Complications (64)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (49)

•Transfusion Complications (5)

•Psychological and Social Complications (30)

Origin/Sponsor

•Australia and New Zealand (8)

•Europe (20)

•North America (610)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (39)

•Active Errors (143)

•Latent Errors (67)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (173)

•Legal and Policy Approaches (64)

•Error Reporting and Analysis (184)

•Communication Improvement (157)

•Human Factors Engineering (103)

•Teamwork (64)

•Specialization of Care (62)

•Logistical Approaches (59)

•Culture of Safety (110)

•Technologic Approaches (102)

•Education and Training (161)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (520)

•Health Care Executives and Administrators (530)

•Non-Health Care Professionals (216)

•Patients (11)

Setting of Care

•Hospitals (497)

•Psychiatric Facilities (2)

•Residential Facilities (5)

•Ambulatory Care (45)

•Outpatient Surgery (2)

•Patient Transport (1)

1 - 20 of 674

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COMMENTARY

Intrahospital transport to the radiology department: risk for adverse events, nursing surveillance, utilization of a MET and practice implications.

Ott LK, Hoffman LA, Hravnak M. J Radiol Nurs. 2011;30:49-52.

COMMENTARY

Nursing mortality and morbidity and journal club cycles: paving the way for nursing autonomy, patient safety, and evidence-based practice.

Staveski S, Leong K, Graham K, Pu L, Roth S. AACN Adv Crit Care. 2012;23:133-141.

COMMENTARY

A model for developing high-reliability teams.

Riley W, Davis SE, Miller KK, McCullough M. J Nurs Manag. 2010;18:556-563.

COMMENTARY

Nursing student medication errors: a case study using root cause analysis.

Dolansky MA, Druschel K, Helba M, Courtney K. J Prof Nurs. 2013;29:102-108.

COMMENTARY

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

COMMENTARY

Is it time to pull the plug on 12-hour shifts?: Part 3. Harm Reduction Strategies if Keeping 12-Hour Shifts.

Geiger-Brown J, Trinkoff AM. J Nurs Adm. 2010;40:357-359.

COMMENTARY

Nurses' role in communication and patient safety.

Nadzam DM. J Nurs Care Qual. 2009;24:184-188.

COMMENTARY

Using simulation to teach nursing students and licensed clinicians obstetric emergencies.

Alderman JT. MCN Am J Matern Child Nurs. 2012;37:394-400.

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

Medication errors in nursing—part 1 and part 2.

Leufer T, Cleary-Holdforth J. Nurse Educ Pract. 2013;13:213-220.

COMMENTARY

Detection of patient risk by nurses: a theoretical framework.

Despins LA, Scott-Cawiezell J, Rouder JN. J Adv Nurs. 2010;66:465-474.

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

Implementing a safe and reliable process for medication administration.

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

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

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 rapid response team: a practical guide.

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

COMMENTARY

Clinical cognition and biomedical informatics: issues of patient safety.

Patel VL, Currie LM. Int J Med Inform. 2005;74:869-885.

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.

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