AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (80)

•Diagnostic Errors (110)

•Identification Errors (59)

•Discontinuities, Gaps, and Hand-Off Problems (324)

•Fatigue and Sleep Deprivation (68)

•Medication Safety (899)

•Medical Complications (296)

•Nonsurgical Procedural Complications (48)

•Surgical Complications (296)

•Transfusion Complications (15)

•Psychological and Social Complications (125)

Origin/Sponsor

•Africa (5)

•Asia (66)

•Australia and New Zealand (101)

•Central and South America (5)

•Europe (432)

•North America (2021)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (1024)

•Active Errors (344)

•Latent Errors (107)

•Near Miss (60)

Approach to Improving Safety

•Quality Improvement Strategies (514)

•Legal and Policy Approaches (117)

•Error Reporting and Analysis (808)

•Communication Improvement (582)

•Human Factors Engineering (252)

•Teamwork (256)

•Specialization of Care (210)

•Logistical Approaches (233)

•Culture of Safety (309)

•Technologic Approaches (486)

•Education and Training (458)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (1858)

•Health Care Executives and Administrators (2162)

•Non-Health Care Professionals (1034)

•Patients (25)

Setting of Care

•Hospitals (1949)

•Psychiatric Facilities (9)

•Residential Facilities (58)

•Ambulatory Care (279)

•Outpatient Surgery (14)

•Patient Transport (22)

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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

Improving teamwork on general medical units: when teams do not work face-to-face.

McComb SA, Henneman EA, Hinchey KT, et al. Jt Comm J Qual Patient Saf. 2012;38:471-478.

STUDY

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

STUDY

Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.

Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Am J Med Qual. 2009;24:278-286.

STUDY

Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.

Hilmas E, Peoples JD. JPEN J Parenter Enteral Nutr. 2012;36(suppl 2):32S-35S.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Assessment of teamwork during structured interdisciplinary rounds on medical units.

O'Leary KJ, Boudreau YN, Creden AJ, Slade ME, Williams MV. J Hosp Med. 2012;7:679-683.

STUDY

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. Int J Med Inform. 2009;78(suppl 1): S69-S76.

STUDY

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

O'Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. J Gen Intern Med. 2010;25:826-832.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

STUDY

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting.

Clay BJ, Halasyamani L, Stucky ER, Greenwald JL, Williams MV. J Hosp Med. 2008;3:465-472.

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

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