AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (227)

•Diagnostic Errors (294)

•Identification Errors (188)

•Discontinuities, Gaps, and Hand-Off Problems (551)

•Fatigue and Sleep Deprivation (113)

•Medication Safety (1550)

•Medical Complications (563)

•Nonsurgical Procedural Complications (126)

•Surgical Complications (607)

•Transfusion Complications (39)

•Psychological and Social Complications (164)

Origin/Sponsor

•Africa (6)

•Asia (69)

•Australia and New Zealand (137)

•Central and South America (11)

•Europe (592)

•North America (4204)

Resource Types

•Clinical Guideline (7)

•Journal Article (3752)

•Legislation/Regulation (62)

•Meeting/Conference (40)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (500)

•Press Release/Announcement (38)

•Special or Theme Issue (92)

•Tools/Toolkit (62)

•Web Resource (140)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (1526)

•Active Errors (915)

•Latent Errors (330)

•Near Miss (104)

Approach to Improving Safety

•Quality Improvement Strategies (1407)

•Legal and Policy Approaches (497)

•Error Reporting and Analysis (1555)

•Communication Improvement (1150)

•Human Factors Engineering (810)

•Teamwork (378)

•Specialization of Care (298)

•Logistical Approaches (357)

•Culture of Safety (634)

•Technologic Approaches (881)

•Education and Training (906)

Clinical Areas

•Allied Health Services (16)

Target Audience

•Health Care Providers (3758)

•Health Care Executives and Administrators (4150)

•Non-Health Care Professionals (1832)

•Patients (388)

Setting of Care

•Hospitals (3035)

•Psychiatric Facilities (17)

•Residential Facilities (87)

•Ambulatory Care (485)

•Outpatient Surgery (60)

•Patient Transport (38)

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STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

STUDY

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

STUDY

Accuracy of radiographic readings in the emergency department.

Petinaux B, Bhat R, Boniface K, Aristizabal J. Am J Emerg Med. 2011;29:18-25.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

STUDY

Strategies for preventing distractions and interruptions in the OR.

Clark GJ. AORN J. 2013;97:702-707.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

STUDY

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

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.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.

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