AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (12)

•Diagnostic Errors (22)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (27)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (55)

•Medical Complications (9)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (54)

•Transfusion Complications (1)

•Psychological and Social Complications (4)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (9)

•Europe (30)

•North America (152)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (65)

•Active Errors (100)

•Latent Errors (65)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (29)

•Legal and Policy Approaches (9)

•Error Reporting and Analysis (63)

•Communication Improvement (36)

•Human Factors Engineering (36)

•Teamwork (10)

•Specialization of Care (7)

•Logistical Approaches (12)

•Culture of Safety (7)

•Technologic Approaches (26)

•Education and Training (46)

Clinical Areas

•Allied Health Services (1)

•Medicine (171)

•Nursing (14)

•Pharmacy (12)

Target Audience

•Health Care Providers (175)

•Health Care Executives and Administrators (140)

•Non-Health Care Professionals (65)

•Patients (1)

Setting of Care

•Hospitals (152)

•Residential Facilities (1)

•Ambulatory Care (11)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 198

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STUDY

Missed lesions at abdominal oncologic CT: lessons learned from quality assurance.

Siewert B, Sosna J, McNamara A, Raptopoulos V, Kruskal JB. Radiographics. 2008;28:623-638.

STUDY

Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Anaesthesia. 2009;64:366-370.

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

STUDY

A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care.

Tamblyn R, Huang A, Taylor L, et al. J Am Med Inform Assoc. 2008;15:430-438.

STUDY

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.

Dean J, Hutchinson A, Hamilton Escoto K, Lawson R. BMC Health Serv Res. 2007;7:89.

STUDY

Waking up the next morning: surgeons' emotional reactions to adverse events.

Luu S, Patel P, St-Martin L, et al. Med Educ. 2012;46:1179-1188.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

STUDY

Communication failures in the operating room: an observational classification of recurrent types and effects.

Lingard L, Espin S, Whyte S, et al. Qual Saf Health Care. 2004;13:330-334.

STUDY

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery.

Bruppacher HR, Alam SK, LeBlanc VR, et al. Anesthesiology. 2010;112:985-992.

STUDY

Preventable anesthesia mishaps: a study of human factors.

Cooper JB, Newbower RS, Long CD, McPeek B. Anesthesiology. 1978;49:399-406.

STUDY

Rate of undesirable events at beginning of academic year: retrospective cohort study.

Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. BMJ. 2009;339:b3974.

STUDY

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN. Arch Dis Child. 2010;95:286-290.

STUDY

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database.

Abeysekera A, Bergman IJ, Kluger MT, Short TG. Anaesthesia. 2005;60:220-227.

STUDY

The struggle to improve patient care in the face of professional boundaries.

Powell AE, Davies HT. Soc Sci Med. 2012;75:807-814.

STUDY

Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.

STUDY

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

Wu RC, Lo V, Morra D, et al. J Am Med Inform Assoc. 2013 Jan 25; [Epub ahead of print].

STUDY

Study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive.

Beecher HK, Todd DP. Ann Surg. 1954;140:1-34.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

STUDY

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

Hartel MJ, Staub LP, Röder C, Eggli S. BMC Health Serv Res. 2011;11:199.

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