AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (199)

•Diagnostic Errors (210)

•Identification Errors (126)

•Discontinuities, Gaps, and Hand-Off Problems (534)

•Fatigue and Sleep Deprivation (117)

•Medication Safety (1230)

•Medical Complications (532)

•Nonsurgical Procedural Complications (111)

•Surgical Complications (477)

•Transfusion Complications (25)

•Psychological and Social Complications (174)

Origin/Sponsor

•Africa (3)

•Asia (46)

•Australia and New Zealand (78)

•Central and South America (4)

•Europe (402)

•North America (4063)

Resource Types

•Clinical Guideline (9)

•Journal Article (3267)

•Legislation/Regulation (67)

•Meeting/Conference (39)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (556)

•Press Release/Announcement (33)

•Special or Theme Issue (81)

•Tools/Toolkit (72)

•Web Resource (135)

•Grant (15)

Error Types

•Epidemiology of Errors and Adverse Events (939)

•Active Errors (637)

•Latent Errors (319)

•Near Miss (84)

Approach to Improving Safety

•Quality Improvement Strategies (1255)

•Legal and Policy Approaches (542)

•Error Reporting and Analysis (1350)

•Communication Improvement (1242)

•Human Factors Engineering (578)

•Teamwork (436)

•Specialization of Care (312)

•Logistical Approaches (355)

•Culture of Safety (955)

•Technologic Approaches (768)

•Education and Training (895)

Clinical Areas

•Allied Health Services (11)

Target Audience

•Health Care Providers (3402)

•Health Care Executives and Administrators (3625)

•Non-Health Care Professionals (1774)

•Patients (416)

Setting of Care

•Hospitals (3141)

•Psychiatric Facilities (20)

•Residential Facilities (86)

•Ambulatory Care (418)

•Outpatient Surgery (49)

•Patient Transport (30)

1 - 20 of 4681

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REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

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.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

COMMENTARY

Do Not Disturb!

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

NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Management of drug shortages in the perioperative setting.

Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.

BOOK/REPORT

Pulse Report 2009: Safety Culture: Staff Perspectives on American Health Care.

South Bend, IN: Press Ganey Associates, Inc: 2009.

BOOK/REPORT

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

COMMENTARY

Patient safety: some progress and many challenges.

Gluck PA. Obstet Gynecol. 2012;120:1149-1159.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

FACT SHEET/FAQS

10 Tips to Help Promote Patient Safety.

Chicago, IL: American Society for Healthcare Risk Management; 2013.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Sustainable patient safety.

Spath S. Hosp Health Netw. December 12, 2006.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

STUDY

Reducing adverse drug events: lessons from a breakthrough series collaborative.

Leape LL, Kabcenell A, Gandhi TK, Carver P, Nolan TW, Berwick DM. Jt Comm J Qual Improv. 2000;26:321-331.

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