AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (212)

•Diagnostic Errors (212)

•Identification Errors (129)

•Discontinuities, Gaps, and Hand-Off Problems (457)

•Fatigue and Sleep Deprivation (89)

•Medication Safety (1194)

•Medical Complications (537)

•Nonsurgical Procedural Complications (116)

•Surgical Complications (513)

•Transfusion Complications (23)

•Psychological and Social Complications (132)

Origin/Sponsor

•Australia and New Zealand (80)

•Central and South America (10)

•Europe (369)

•North America (3513)

Resource Types

•Audiovisual (43)

•Bibliography (2)

•Book/Report (200)

•Clinical Guideline (12)

•Journal Article (3007)

•Legislation/Regulation (66)

•Meeting/Conference (27)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (372)

•Press Release/Announcement (30)

•Special or Theme Issue (62)

•Tools/Toolkit (70)

•Web Resource (108)

Error Types

•Epidemiology of Errors and Adverse Events (913)

•Active Errors (664)

•Latent Errors (255)

•Near Miss (75)

Approach to Improving Safety

•Quality Improvement Strategies (1209)

•Legal and Policy Approaches (344)

•Error Reporting and Analysis (1082)

•Communication Improvement (990)

•Human Factors Engineering (647)

•Teamwork (373)

•Specialization of Care (304)

•Logistical Approaches (271)

•Culture of Safety (520)

•Technologic Approaches (679)

•Education and Training (789)

Clinical Areas

•Allied Health Services (9)

•Dentistry (8)

•Medicine (2780)

•Nursing (361)

•Pharmacy (406)

Target Audience

•Health Care Providers (3306)

•Health Care Executives and Administrators (3359)

•Non-Health Care Professionals (1436)

•Patients (272)

Setting of Care

•Hospitals (2539)

•Psychiatric Facilities (15)

•Residential Facilities (71)

•Ambulatory Care (356)

•Outpatient Surgery (42)

•Patient Transport (33)

1 - 20 of 4055

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STUDY

A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.

Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

STUDY

Real time patient safety audits: improving safety every day.

Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.

STUDY

classic

The effect of multidisciplinary care teams on intensive care unit mortality.

Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. Arch Intern Med. 2010;170:369-376.

STUDY

Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients.

Rivkin A, Yin H. J Crit Care. 2011;26:104.e1-104.e6.

COMMENTARY classic

classic

Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.

COMMENTARY

Random safety auditing, root cause analysis, failure mode and effects analysis.

Ursprung R, Gray J. Clin Perinatol. 2010;37:141-165.

STUDY

Reducing iatrogenic risks: ICU–acquired delirium and weakness—crossing the quality chasm.

Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Chest. 2010;138:1224-1233.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

CLINICAL GUIDELINE

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med. 2013;41:580-637.

STUDY

classic

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Am Surg. 2009;75:1171-1174.

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.

STUDY

The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events.

van Gaal BG, Schoonhoven L, Hulscher ME, et al. BMC Health Serv Res. 2009;9:58.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

BOOK/REPORT

Back to Basics.

Gima Z, Gosselar P, Levine A, Lincoln T, Ramirez A. Washington, DC: Public Citizen; August 6, 2009.

STUDY

Value of human factors to medication and patient safety in the intensive care unit.

Scanlon MC, Karsh BT. Crit Care Med. 2010;38(suppl 6):S90-S96.

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