AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (55)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (80)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (143)

•Medical Complications (58)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (67)

•Transfusion Complications (4)

•Psychological and Social Complications (29)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (3)

•Europe (19)

•North America (561)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (21)

•Active Errors (204)

•Latent Errors (72)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (168)

•Legal and Policy Approaches (94)

•Error Reporting and Analysis (174)

•Communication Improvement (198)

•Human Factors Engineering (109)

•Teamwork (55)

•Specialization of Care (48)

•Logistical Approaches (41)

•Culture of Safety (88)

•Technologic Approaches (98)

•Education and Training (144)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (587)

•Health Care Executives and Administrators (497)

•Non-Health Care Professionals (223)

•Patients (21)

Setting of Care

•Hospitals (351)

•Psychiatric Facilities (4)

•Residential Facilities (14)

•Ambulatory Care (54)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 636

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COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

COMMENTARY

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Ann Emerg Med. 2010;55:341-344.

COMMENTARY

Advancing nursing home quality through quality improvement itself.

Werner RM, Konetzka RT. Health Aff (Millwood). 2010;29:81-86.

COMMENTARY

Dealing honestly with an honest mistake.

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

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

COMMENTARY

Structured communication for patient safety in emergency medical services: a legal case report.

Greenwood MJ, Heninger JR. Prehosp Emerg Care. 2010;14:345-348.

COMMENTARY

ISMP medication error report analysis.

Cohen MC. Hosp Pharm. 2009;44:374-378.

COMMENTARY

The Wrongful Resuscitation

Teno JM. AHRQ WebM&M [serial online]. April 2008.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

COMMENTARY

Shortage of perioperative drugs: implications for anesthesia practice and patient safety.

De Oliveira GS Jr, Theilken LS, McCarthy RJ. Anesth Analg. 2011;113:1429-1435.

COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

COMMENTARY

Tubing safety in the obstetric setting: preventing medication errors.

Broussard BS. Nurs Womens Health. 2009;13:155-158.

COMMENTARY

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

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

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

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

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

Eytan T. AHRQ WebM&M [serial online]. October 2008.

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.

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