AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (26)

•Diagnostic Errors (52)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (160)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (159)

•Medical Complications (51)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (58)

•Transfusion Complications (4)

•Psychological and Social Complications (35)

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•Asia (1)

•Australia and New Zealand (5)

•Central and South America (2)

•Europe (23)

•North America (624)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (61)

•Active Errors (127)

•Latent Errors (75)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (174)

•Legal and Policy Approaches (85)

•Error Reporting and Analysis (157)

•Communication Improvement (222)

•Human Factors Engineering (90)

•Teamwork (71)

•Specialization of Care (62)

•Logistical Approaches (68)

•Culture of Safety (109)

•Technologic Approaches (121)

•Education and Training (213)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (547)

•Health Care Executives and Administrators (516)

•Non-Health Care Professionals (288)

•Patients (15)

Setting of Care

•Hospitals (497)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (55)

•Outpatient Surgery (5)

•Patient Transport (4)

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COMMENTARY classic

The new recommendations on duty hours from the ACGME Task Force.

Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.

COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

COMMENTARY

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

Guralnick S, Rushton J, Bale JF Jr, Norwood V, Trimm F, Schumacher D. Pediatrics. 2010;125:786-790.

COMMENTARY

The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.

Iglehart JK. N Engl J Med. 2010;363:1589-1591.

COMMENTARY

Perspective: ten thousand hours to patient safety, sooner or later.

Pellegrini VD Jr. Acad Med. 2012;87:164-167.

COMMENTARY

Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.

Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape L. Nat Sci Sleep. 2011;3:47-85.

COMMENTARY

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Pastores SM, O’Connor MF, Kleinpell RM, et al. Crit Care Med. 2011;39:2540-2549.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

COMMENTARY

Sleep deprivation, physician performance, and patient safety.

Olson EJ, Drage LA, Auger RR. Chest. 2009;136:1389-1396.

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

COMMENTARY

Development and implementation of an oral sign-out skills curriculum.

Horwitz LI, Moin T, Green ML. J Gen Intern Med. 2007;22:1470-1474.

COMMENTARY

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 Institute of Medicine resident duty hours recommendations.

Wagner MJ, Wolf S, Promes S, et al. J Emerg Med. 2010;39:348-355.

COMMENTARY

Building physician work hour regulations from first principles and best evidence.

Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

COMMENTARY

Putting the sleepy resident issue to bed: federal legislation is not the answer to excessive medical resident working hours.

Stone JD. Suffolk Univ Law Rev. 2007;40:745-767.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

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.

COMMENTARY

Professionalism in the era of duty hours: time for a shift change?

Arora VM, Farnan JM, Humphrey HJ. JAMA. 2012;308:2195-2196.

COMMENTARY

Residents' duty hours—toward an empirical narrative.

Rosenbaum L, Lamas D. N Engl J Med. 2012;367:2044-2049.

COMMENTARY

Sleep and the medical profession.

Parthasarathy S. Curr Opin Pulm Med. 2005;11:507-512.

COMMENTARY

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.

Schumacher DJ, Slovin SR, Riebschleger MP, Englander R, Hicks PJ, Carraccio C. Acad Med. 2012;87:883-888.

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