AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (23)

•Diagnostic Errors (21)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (89)

•Fatigue and Sleep Deprivation (160)

•Medication Safety (99)

•Medical Complications (61)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (77)

•Transfusion Complications (1)

•Psychological and Social Complications (193)

Origin/Sponsor

•Australia and New Zealand (33)

•Central and South America (1)

•Europe (124)

•North America (692)

Resource Types

•Audiovisual (3)

•Book/Report (53)

•Journal Article (682)

•Legislation/Regulation (7)

•Meeting/Conference (12)

•Newspaper/Magazine Article (51)

•Press Release/Announcement (7)

•Special or Theme Issue (27)

•Tools/Toolkit (11)

•Web Resource (20)

Error Types

•Epidemiology of Errors and Adverse Events (113)

•Active Errors (64)

•Latent Errors (52)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (176)

•Legal and Policy Approaches (103)

•Error Reporting and Analysis (226)

•Communication Improvement (189)

•Human Factors Engineering (94)

•Teamwork (120)

•Specialization of Care (29)

•Logistical Approaches (198)

•Culture of Safety (219)

•Technologic Approaches (78)

•Education and Training (220)

Clinical Areas

•Allied Health Services (4)

•Medicine (476)

•Nursing (67)

•Pharmacy (14)

Target Audience

•Health Care Providers (474)

•Health Care Executives and Administrators (791)

•Non-Health Care Professionals (705)

•Patients (28)

Setting of Care

•Hospitals (503)

•Psychiatric Facilities (4)

•Residential Facilities (8)

•Ambulatory Care (44)

•Outpatient Surgery (4)

•Patient Transport (7)

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COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Building physician work hour regulations from first principles and best evidence.

Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

MULTI-USE WEBSITE

Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety.

Institute of Medicine.

BOOK/REPORT

Strategies for Addressing Health Care Worker Fatigue.

Oakbrook Terrace, IL: Joint Commission Resources; 2008. ISBN: 9781599402291.

REVIEW

Restricting resident work hours: the good, the bad, and the ugly.

Peets A, Ayas NT. Crit Care Med. 2012;40:960-966.

NEWSPAPER/MAGAZINE ARTICLE

Exhausted workforce increases the risk of errors.

ISMP Medication Safety Alert. June 2, 2005.

STUDY

Cost implications of reduced work hours and workloads for resident physicians.

Nuckols TK, Bhattacharya J, Miller Wolman D, Ulmer C, Escarce JJ. N Engl J Med. 2009;360:2202-2215.

STUDY

classic

Effective implementation of work-hour limits and systemic improvements.

Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33(suppl 1):19-29.

BOOK/REPORT classic

classic

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.

STUDY

classic

Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities.

Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-1153.

STUDY

Explaining ethnic disparities in patient safety: a qualitative analysis.

Suurmond J, Uiters E, De Bruijne MC, Stronks K, Essink-Bot ML. Am J Public Health. 2010;100 (suppl 1):S113-117.

STUDY

Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial.

Desai SV, Feldman L, Brown L, et al. JAMA Intern Med. 2013;173:649-655.

COMMENTARY

Duty hour reform in a shifting medical landscape.

Jena AB, Prasad V. J Gen Intern Med. 2013 Apr 9; [Epub ahead of print].

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

REVIEW

Intimidation: a concept analysis.

Lamontagne C. Nurs Forum. 2010;45:54-65.

STUDY

classic

Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.

Landrigan CP, Fahrenkopf AM, Lewin D, et al. Pediatrics. 2008;122:250-258.

STUDY

classic

Mortality among patients admitted to hospitals on weekends as compared with weekdays.

Bell CM, Redelmeier DA. N Engl J Med. 2001;345:663-668.

STUDY

Special report: suicidal ideation among American surgeons.

Shanafelt TD, Balch CM, Dyrbye L, et al. Arch Surg. 2011;146:54-62.

STUDY

ACGME duty-hour recommendations—a national survey of residency program directors.

Antiel RM, Thompson SM, Reed DA, et al. N Engl J Med. 2010;363:e12.

STUDY

The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support.

Lown BA, Manning CF. Acad Med. 2010;85:1073-1081.

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