AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (36)

•Identification Errors (20)

•Discontinuities, Gaps, and Hand-Off Problems (55)

•Fatigue and Sleep Deprivation (14)

•Medication Safety (145)

•Medical Complications (49)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (69)

•Transfusion Complications (3)

•Psychological and Social Complications (34)

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•Asia (3)

•Australia and New Zealand (13)

•Central and South America (1)

•Europe (24)

•North America (666)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (26)

•Active Errors (115)

•Latent Errors (48)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (176)

•Legal and Policy Approaches (111)

•Error Reporting and Analysis (226)

•Communication Improvement (200)

•Human Factors Engineering (110)

•Teamwork (69)

•Specialization of Care (47)

•Logistical Approaches (42)

•Culture of Safety (119)

•Technologic Approaches (103)

•Education and Training (151)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (617)

•Health Care Executives and Administrators (626)

•Non-Health Care Professionals (274)

•Patients (25)

Setting of Care

•Hospitals (356)

•Residential Facilities (4)

•Ambulatory Care (46)

•Outpatient Surgery (7)

•Patient Transport (2)

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COMMENTARY

Drill down with root cause analysis.

McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

COMMENTARY

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

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

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

COMMENTARY classic

Disclosure of medical injury to patients: an improbable risk management strategy.

Studdert DM, Mello MM, Gawande AA, Brennan TA, Wang YC. Health Aff (Millwood). 2007;26:215-226.

COMMENTARY

Crossing to safety: transforming healthcare organizations for patient safety.

Ralston JD, Larson EB. J Postgrad Med. 2005;51:61-67.

COMMENTARY

Lawyers say 'sorry' may sink you in court.

Butcher L. Physician Exec. March-April 2006;32:20-24.

COMMENTARY

We're not your enemy: an appeal from a consumer to re-imagine tort reform.

Sheridan SS, Hatlie MJ. Patient Saf Qual Healthc. July/August 2007;4:22-26.

COMMENTARY

What happens when things go wrong?

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

COMMENTARY

View the world through a different lens: shadowing another provider.

Thompson DA, Holzmueller CG, Lubomski L, Pronovost PJ. Jt Comm J Qual Patient Saf. 2008;34:614-618.

COMMENTARY

Successful remediation of patient safety incidents: a tale of two medication errors.

Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.

COMMENTARY

A piece of my mind. Mistakes.

Lesnewski R. JAMA. 2006;296:1327-1328.

COMMENTARY

Sued for misdiagnosis? It could happen to you.

Lippman H, Davenport J. J Fam Pract. 2010;59:498-508.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

COMMENTARY

Medical error, malpractice and complications: a moral geography.

Zientek DM. HEC Forum. 2010;22:145-157.

COMMENTARY

A mediation skills model to manage disclosure of errors and adverse events to patients.

Liebman CB, Hyman CS. Health Aff (Millwood). July/Aug 2004;23:22-32.

COMMENTARY

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

COMMENTARY

Apology in medical practice: an emerging clinical skill.

Lazare A. JAMA. 2006;296:1401-1404.

COMMENTARY

Disclosing unanticipated outcomes to patients: the art and practice.

Gallagher TH, Denham CR, Leape LL, Amori G, Levinson W. J Patient Saf. 2007;3:158-165.

COMMENTARY

Miles to go: an introduction to the 5 Million Lives Campaign.

McCannon CJ, Hackbarth AD, Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:477-484.

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