AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (66)

•Diagnostic Errors (102)

•Identification Errors (50)

•Discontinuities, Gaps, and Hand-Off Problems (355)

•Fatigue and Sleep Deprivation (66)

•Medication Safety (512)

•Medical Complications (204)

•Nonsurgical Procedural Complications (39)

•Surgical Complications (224)

•Transfusion Complications (9)

•Psychological and Social Complications (65)

Origin/Sponsor

•Africa (2)

•Asia (18)

•Australia and New Zealand (40)

•Central and South America (5)

•Europe (156)

•North America (1475)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (653)

•Active Errors (263)

•Latent Errors (113)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (321)

•Legal and Policy Approaches (66)

•Error Reporting and Analysis (505)

•Communication Improvement (408)

•Human Factors Engineering (159)

•Teamwork (136)

•Specialization of Care (160)

•Logistical Approaches (173)

•Culture of Safety (161)

•Technologic Approaches (299)

•Education and Training (316)

Clinical Areas

•Allied Health Services (5)

•Medicine (1352)

•Nursing (184)

•Pharmacy (157)

Target Audience

•Health Care Providers (1284)

•Health Care Executives and Administrators (1433)

•Non-Health Care Professionals (579)

•Patients (18)

Setting of Care

•Hospitals (1236)

•Psychiatric Facilities (5)

•Residential Facilities (32)

•Ambulatory Care (149)

•Outpatient Surgery (12)

•Patient Transport (16)

1 - 20 of 1702

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STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

STUDY

Who's covering our loved ones: surprising barriers in the sign-out process.

Antonoff MB, Berdan EA, Kirchner VA, et al. Am J Surg. 2013;205:77-84.

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

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

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

Checklists change communication about key elements of patient care.

Newkirk M, Pamplin JC, Kuwamoto R, Allen DA, Chung KK. J Trauma Acute Care Surg. 2012;73(2 suppl 1):S75-S82.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

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

ED handoffs: observed practices and communication errors.

Maughan BC, Lei L, Cydulka RK. Am J Emerg Med. 2011;29:502-511.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

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

Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.

Droogh JM, Kruger HL, Ligtenberg JJM, Zijlstra JG. Jt Comm J Qual Patient Saf. 2012;38:554-559.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Building collaborative teams in neonatal intensive care.

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

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

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

STUDY

Inappropriate medications in elderly ICU survivors: where to intervene?

Morandi A, Vasilevskis EE, Pandharipande PP, et al. Arch Intern Med. 2011;171:1032-1034.

STUDY

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

Coverdill JE, Carbonell AM, Fryer J, et al. Acad Med. 2010;85:S72-S75.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

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