AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (68)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (136)

•Fatigue and Sleep Deprivation (49)

•Medication Safety (312)

•Medical Complications (117)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (191)

•Transfusion Complications (4)

•Psychological and Social Complications (244)

Origin/Sponsor

•Africa (2)

•Asia (32)

•Australia and New Zealand (196)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (1175)

•Legislation/Regulation (16)

•Meeting/Conference (5)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (119)

•Press Release/Announcement (12)

•Special or Theme Issue (19)

•Tools/Toolkit (11)

•Web Resource (12)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (319)

•Active Errors (216)

•Latent Errors (93)

•Near Miss (29)

Approach to Improving Safety

•Quality Improvement Strategies (315)

•Legal and Policy Approaches (210)

•Error Reporting and Analysis (618)

•Communication Improvement (465)

•Human Factors Engineering (169)

•Teamwork (161)

•Specialization of Care (70)

•Logistical Approaches (97)

•Culture of Safety (209)

•Technologic Approaches (153)

•Education and Training (262)

Clinical Areas

•Allied Health Services (8)

Target Audience

•Health Care Providers (889)

•Health Care Executives and Administrators (1352)

•Non-Health Care Professionals (786)

•Patients (86)

Setting of Care

•Hospitals (782)

•Psychiatric Facilities (6)

•Residential Facilities (12)

•Ambulatory Care (98)

•Outpatient Surgery (14)

•Patient Transport (14)

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BOOK/REPORT

Risk Management Pearls on Disclosure of Adverse Events.

Amori G. Chicago, IL: American Society for Healthcare Risk Management; 2006.

STUDY

Doctors' stress responses and poor communication performance in simulated bad-news consultations.

Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J. Acad Med. 2009;84:1595-1602.

COMMENTARY

In Conversation with…Thomas H. Gallagher, MD

AHRQ WebM&M [serial online]. January 2009.

STUDY

Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study.

Iedema R, Allen S, Britton K, et al. BMJ. 2011;343:d4423.

REVIEW

Narrative review: do state laws make it easier to say "I'm sorry?"

McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

STUDY

Assessing residents' communication skills: disclosure of an adverse event to a standardized patient.

Posner G, Nakajima A. J Obstet Gynaecol Can. 2011;33:262-268.

COMMENTARY

Medication errors: immunisation.

Bird S. Aust Fam Physician. 2006;35:735-737.

COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

STUDY

Patient perspectives of patient–provider communication after adverse events.

Duclos CW, Eichler M, Taylor L, et al. Int J Qual Health Care. 2005;17:479-86.

COMMENTARY

In Conversation with…Gerald B. Hickson, MD.

AHRQ WebM&M [serial online]. December 2009.

ORGANIZATIONAL POLICY/GUIDELINES

A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department.

Sentinel Event Alert. 2010 Nov 17;(46):1-4.

STUDY

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.

López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

COMMENTARY

Successful remediation of patient safety incidents: a tale of two medication errors.

Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.

STUDY

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality?: Evidence from survey data.

Helmchen LA, Richards MR, McDonald TB. Med Care. 2010;48:955-961.

STUDY

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.

STUDY

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation.

Bell SK, Smulowitz PB, Woodward AC, et al. Milbank Q. 2012;90:682-705.

COMMENTARY

Apologies and medical error.

Robbennolt JK. Clin Orthop Relat Res. 2009;467:376-382.

REVIEW

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors.

Kaldjian LC, Jones EW, Rosenthal GE, Tripp-Reimer T, Hillis SL. J Gen Intern Med. 2006;21:942-948.

STUDY

Managing the after effects of serious patient safety incidents in the NHS: an online survey study.

Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.

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