AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (12)

•Diagnostic Errors (65)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (70)

•Fatigue and Sleep Deprivation (37)

•Medication Safety (129)

•Medical Complications (22)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (70)

•Transfusion Complications (1)

•Psychological and Social Complications (25)

Origin/Sponsor

•Asia (2)

•Europe (11)

•North America (469)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (169)

•Active Errors (54)

•Latent Errors (15)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (68)

•Legal and Policy Approaches (22)

•Error Reporting and Analysis (148)

•Communication Improvement (91)

•Human Factors Engineering (25)

•Teamwork (25)

•Specialization of Care (26)

•Logistical Approaches (64)

•Culture of Safety (27)

•Technologic Approaches (84)

•Education and Training (100)

Clinical Areas

•Allied Health Services (1)

•Medicine (365)

•Nursing (8)

•Pharmacy (35)

Target Audience

•Health Care Providers (477)

•Health Care Executives and Administrators (308)

•Non-Health Care Professionals (161)

•Patients (10)

Setting of Care

•Hospitals (277)

•Residential Facilities (4)

•Ambulatory Care (50)

•Outpatient Surgery (5)

•Patient Transport (2)

1 - 20 of 480

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STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

STUDY

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

Sarkar U, Bonacum D, Strull W, et al. BMJ Qual Saf. 2012;21:641-648.

STUDY

When the bone flap hits the floor.

Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

STUDY

The prevalence of wrong level surgery among spine surgeons.

Mody MG, Nourbakhsh A, Stahl DL, Gibbs M, Alfawareh M, Garges KJ. Spine. 2008;33:194-198.

STUDY

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

Smith ER, Butler WE, Barker FG 2nd. J Neurosurg. 2006;105(suppl 3):169-176.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

STUDY

Bedside detection of awareness in the vegetative state: a cohort study.

Cruse D, Chennu S, Chatelle C, et al. Lancet. 2012;378:2088-2094.

STUDY

Examining the diagnostic justification abilities of fourth-year medical students.

Williams RG, Klamen DL. Acad Med. 2012;87:1008-1014.

STUDY

Types and origins of diagnostic errors in primary care settings.

Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. JAMA Intern Med. 2013;173:418-425.

STUDY

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. J Gen Intern Med. 2006;21:758-763.

STUDY

Neurologic patient safety: an in-depth study of malpractice claims.

Glick TH, Cranberg LD, Hanscom RB, Sato L. Neurology. 2005;65:1284-1286.

STUDY

Cognitive balanced model: a conceptual scheme of diagnostic decision making.

Lucchiari C, Pravettoni G. J Eval Clin Pract. 2012;18:82-88.

STUDY

Adverse event protocol for interventional pain medicine: the importance of an organized response.

Sitzman BT. Pain Med. 2008;9:S108-S112.

STUDY

Diagnostic pitfalls in paediatric ischaemic stroke.

Braun KP, Kappelle LJ, Kirkham FJ, Deveber G. Dev Med Child Neurol. 2006;48:985-990.

STUDY

Missed diagnoses by urologists resulting in malpractice payment.

Badger WJ, Moran ME, Abraham C, Yarlagadda B, Perrotti M. J Urol. 2007;178;2537-2539.

STUDY

Overestimation of clinical diagnostic performance caused by low necropsy rates.

Shojania KG, Burton EC, McDonald KM, Goldman L. Qual Saf Health Care. 2005;14:408-413.

STUDY

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. J Gen Intern Med. 2012;27:1416-1423.

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