AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (81)

•Diagnostic Errors (110)

•Identification Errors (57)

•Discontinuities, Gaps, and Hand-Off Problems (364)

•Fatigue and Sleep Deprivation (54)

•Medication Safety (745)

•Medical Complications (257)

•Nonsurgical Procedural Complications (46)

•Surgical Complications (262)

•Transfusion Complications (12)

•Psychological and Social Complications (75)

Origin/Sponsor

•Africa (4)

•Asia (33)

•Australia and New Zealand (69)

•Central and South America (6)

•Europe (275)

•North America (1700)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (868)

•Active Errors (383)

•Latent Errors (96)

•Near Miss (53)

Approach to Improving Safety

•Quality Improvement Strategies (414)

•Legal and Policy Approaches (80)

•Error Reporting and Analysis (582)

•Communication Improvement (538)

•Human Factors Engineering (220)

•Teamwork (171)

•Specialization of Care (186)

•Logistical Approaches (170)

•Culture of Safety (191)

•Technologic Approaches (409)

•Education and Training (363)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1622)

•Health Care Executives and Administrators (1754)

•Non-Health Care Professionals (729)

•Patients (19)

Setting of Care

•Hospitals (1480)

•Psychiatric Facilities (8)

•Residential Facilities (69)

•Ambulatory Care (242)

•Outpatient Surgery (12)

•Patient Transport (23)

1 - 20 of 2085

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STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

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

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Building collaborative teams in neonatal intensive care.

Brodsky D, Gupta M, Quinn M, et al. BMJ Qual Saf. 2013;374-382.

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

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. J Hosp Med. 2011;6:68-72.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

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 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

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Pediatrics. 2009;124:945-950.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

STUDY

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

STUDY

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

Kalina M, Tinkoff G, Gleason W, Veneri P, Fulda G. Pediatr Emerg Care. 2009;25:444-446.

STUDY

Medication reconciliation: developing and implementing a program.

Schwarz M, Wyskiel R. Crit Care Nurs Clin North Am. 2006;18:503-507.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Medication reconciliation in ambulatory care: attempts at improvement.

Nassaralla CL, Naessens JM, Hunt VL, et al. Qual Saf Health Care. 2009;18:402-407.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

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