AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (109)

•Diagnostic Errors (259)

•Identification Errors (80)

•Discontinuities, Gaps, and Hand-Off Problems (299)

•Fatigue and Sleep Deprivation (36)

•Medication Safety (726)

•Medical Complications (302)

•Nonsurgical Procedural Complications (77)

•Surgical Complications (285)

•Transfusion Complications (18)

•Psychological and Social Complications (90)

Origin/Sponsor

•Africa (9)

•Asia (41)

•Australia and New Zealand (91)

•Central and South America (11)

•Europe (622)

•North America (1662)

Resource Types

•Clinical Guideline (1)

•Journal Article (1801)

•Legislation/Regulation (34)

•Meeting/Conference (30)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (173)

•Press Release/Announcement (29)

•Special or Theme Issue (47)

•Tools/Toolkit (33)

•Web Resource (82)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (1015)

•Active Errors (405)

•Latent Errors (152)

•Near Miss (49)

Approach to Improving Safety

•Quality Improvement Strategies (655)

•Legal and Policy Approaches (287)

•Error Reporting and Analysis (830)

•Communication Improvement (606)

•Human Factors Engineering (303)

•Teamwork (188)

•Specialization of Care (163)

•Logistical Approaches (143)

•Culture of Safety (352)

•Technologic Approaches (430)

•Education and Training (426)

Clinical Areas

•Allied Health Services (10)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (2201)

•Health Care Executives and Administrators (2171)

•Non-Health Care Professionals (970)

•Patients (198)

Setting of Care

•Hospitals (1437)

•Psychiatric Facilities (18)

•Residential Facilities (47)

•Ambulatory Care (376)

•Outpatient Surgery (31)

•Patient Transport (30)

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STUDY

Undiagnosed breast cancer at MR imaging: analysis of causes.

Pages EB, Millet I, Hoa D, Doyon FC, Taourel P. Radiology. 2012;264:40-50.

STUDY

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.

Watts RG, Parsons K. Pediatr Blood Cancer. 2013 Mar 20; [Epub ahead of print].

STUDY

Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better?

Crocker M, Cato-Addison WB, Pushpananthan S, Jones TL, Anderson J, Bell BA. Br J Neurosurg. 2010;24:391-395.

COMMENTARY

Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment.

Wahls T. J Ambul Care Manage. 2007;30:338-343.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

BOOK/REPORT

Why Current Breast Pathology Practices Must Be Evaluated.

Dallas, TX: Susan G. Komen Breast Cancer Foundation; June 2006.

NEWSPAPER/MAGAZINE ARTICLE

Spike in MR imaging accidents underscores need for regulation.

Radiological Society of North America. RSNA News; October 2010.

BOOK/REPORT

Patient Safety.

Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.

STUDY

The care transitions intervention: results of a randomized controlled trial.

Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.

BOOK/REPORT

IBEAS: A Pioneer Study on Patient Safety in Latin America: Towards Safer Hospital Care.

Geneva, Switzerland: World Health Organization; 2011.

STUDY

Measuring perceptions of safety climate in primary care: a cross-sectional study.

de Wet C, Johnson P, Mash R, McConnachie A, Bowie P. J Eval Clin Pract. 2012;18:135-142.

COMMENTARY

Failure to Latch

Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.

STUDY

Electronic health record-based surveillance of diagnostic errors in primary care.

Singh H, Giardina TD, Forjuoh SN, et al. BMJ Qual Saf. 2012;22:93-100.

BOOK/REPORT

Quarterly National Reporting and Learning System Data Summary.

National Patient Safety Agency. London, UK: National Health Service.

BOOK/REPORT

Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.

Baker M. Manchester, England: NHS North West; February 2007.

STUDY

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety.

Simons PAM, Houben RMA, Backes HH, Pijls RFG, Groothuis S. Int J Qual Health Care. 2010;22:187-193.

STUDY

Exploring situational awareness in diagnostic errors in primary care.

Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

MEASUREMENT TOOL/INDICATOR

2012 ISMP International Medication Safety Self Assessment for Oncology.

Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.

STUDY

Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT.

McCreadie G, Oliver TB. Clin Radiol. 2009;64:491-499; discussion 500-501.

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