AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (60)

•Diagnostic Errors (90)

•Identification Errors (47)

•Discontinuities, Gaps, and Hand-Off Problems (307)

•Fatigue and Sleep Deprivation (39)

•Medication Safety (393)

•Medical Complications (173)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (319)

•Transfusion Complications (10)

•Psychological and Social Complications (46)

Origin/Sponsor

•Africa (2)

•Asia (32)

•Australia and New Zealand (65)

•Central and South America (6)

•Europe (295)

•North America (997)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (632)

•Active Errors (266)

•Latent Errors (63)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (290)

•Legal and Policy Approaches (52)

•Error Reporting and Analysis (423)

•Communication Improvement (385)

•Human Factors Engineering (180)

•Teamwork (142)

•Specialization of Care (110)

•Logistical Approaches (105)

•Culture of Safety (124)

•Technologic Approaches (216)

•Education and Training (240)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1114)

•Health Care Executives and Administrators (1307)

•Non-Health Care Professionals (458)

•Patients (10)

Setting of Care

•Hospitals (1108)

•Psychiatric Facilities (6)

•Residential Facilities (30)

•Ambulatory Care (111)

•Outpatient Surgery (13)

•Patient Transport (20)

1 - 20 of 1403

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STUDY

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

STUDY

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers.

Li P, Stelfox HT, Ghali WA. Am J Med. 2011;124:860-867.

STUDY

Postoperative handover: problems, pitfalls, and prevention of error.

Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-176.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams.

Schraagen JM. Theor Issues Ergon Sci. 2011;12:256-272.

STUDY

Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.

Chu MWA, Stitt LW, Fox SA, et al. Arch Surg. 2011;146:1080-1085.

STUDY

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

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 value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

Hess DR, Tokarczyk A, O’Malley M, Gavaghan S, Sullivan J, Schmidt U. Chest. 2010;138:1475-1479.

STUDY

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

Schraagen JM, Schouten T, Smit M, et al. BMJ Qual Saf. 2011;20:599-603.

STUDY

Hospital admission medication reconciliation in medically complex children: an observational study.

Stone BL, Boehme S, Mundorff MB, Maloney CG, Srivastava R. Arch Dis Child. 2010;95:250-255.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

STUDY

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-2912.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

STUDY

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

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