AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (137)

•Diagnostic Errors (133)

•Identification Errors (84)

•Discontinuities, Gaps, and Hand-Off Problems (432)

•Fatigue and Sleep Deprivation (102)

•Medication Safety (1216)

•Medical Complications (415)

•Nonsurgical Procedural Complications (56)

•Surgical Complications (277)

•Transfusion Complications (17)

•Psychological and Social Complications (265)

Origin/Sponsor

•Australia and New Zealand (81)

•Central and South America (3)

•Europe (372)

•North America (3373)

Resource Types

•Audiovisual (50)

•Bibliography (2)

•Book/Report (266)

•Clinical Guideline (4)

•Journal Article (2695)

•Legislation/Regulation (40)

•Meeting/Conference (29)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (482)

•Press Release/Announcement (17)

•Special or Theme Issue (68)

•Tools/Toolkit (63)

•Web Resource (113)

Error Types

•Epidemiology of Errors and Adverse Events (747)

•Active Errors (433)

•Latent Errors (217)

•Near Miss (45)

Approach to Improving Safety

•Quality Improvement Strategies (922)

•Legal and Policy Approaches (471)

•Error Reporting and Analysis (1019)

•Communication Improvement (918)

•Human Factors Engineering (388)

•Teamwork (328)

•Specialization of Care (257)

•Logistical Approaches (290)

•Culture of Safety (628)

•Technologic Approaches (937)

•Education and Training (1070)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

•Dentistry (2)

•Medicine (2515)

•Nursing (269)

•Pharmacy (474)

Target Audience

•Health Care Providers (2457)

•Health Care Executives and Administrators (3115)

•Non-Health Care Professionals (2003)

•Patients (341)

Setting of Care

•Hospitals (2407)

•Psychiatric Facilities (13)

•Residential Facilities (57)

•Ambulatory Care (342)

•Outpatient Surgery (23)

•Patient Transport (12)

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COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

Hagland M. Healthc Informatics. 2009;26:40-44.

NEWSPAPER/MAGAZINE ARTICLE

Effective use of medication-related decision support in CPOE.

Metzger JB, Welebob E, Turisco F, Classen DC. Patient Saf Qual Healthc. Sept/Oct 2008;5:16-24.

STUDY

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.

Sittig DF, Ash JS, Guappone KP, Campbell EM, Dykstra RH. Int J Med Inform. 2008;77:440-447.

STUDY

Using implementation safety indicators for CPOE implementation.

Weir CR, McCarthy CA. Jt Comm J Qual Patient Saf. 2009;35:21-28.

NEWSPAPER/MAGAZINE ARTICLE

Piecing together medication administration.

Anderson HJ. Health Data Manage. May 1, 2009;17:22.

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

STUDY

classic

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

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

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.

STUDY

classic

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010;126:14-21.

BOOK/REPORT

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

STUDY

The effects of computerized provider order entry implementation on communication in intensive care units.

Hoonakker PL, Carayon P, Walker JM, Brown RL, Cartmill RS. Int J Med Inform. 2013;82:e107-e117.

AWARD RECIPIENT

Announcing 2009 Leapfrog top hospitals.

Washington, DC: Leapfrog Group; December 4, 2009.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

Leung AA, Keohane C, Lipsitz S, et al. J Am Med Inform Assoc. 2013 Apr 18; [Epub ahead of print].

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

STUDY

Early cost and safety benefits of an inpatient electronic health record.

Zlabek JA, Wickus JW, Mathiason MA. J Am Med Inform Assoc. 2011;18:169-172.

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