AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (102)

•Diagnostic Errors (85)

•Identification Errors (53)

•Discontinuities, Gaps, and Hand-Off Problems (242)

•Fatigue and Sleep Deprivation (88)

•Medication Safety (574)

•Medical Complications (283)

•Nonsurgical Procedural Complications (48)

•Surgical Complications (248)

•Transfusion Complications (11)

•Psychological and Social Complications (119)

Origin/Sponsor

•Africa (3)

•Asia (11)

•Australia and New Zealand (32)

•Central and South America (3)

•Europe (170)

•North America (2584)

Resource Types

•Clinical Guideline (2)

•Journal Article (1827)

•Legislation/Regulation (45)

•Meeting/Conference (35)

•Newsletter/Journal (9)

•Newspaper/Magazine Article (376)

•Press Release/Announcement (16)

•Special or Theme Issue (65)

•Tools/Toolkit (39)

•Web Resource (81)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (361)

•Active Errors (269)

•Latent Errors (350)

•Near Miss (34)

Approach to Improving Safety

•Quality Improvement Strategies (752)

•Legal and Policy Approaches (508)

•Error Reporting and Analysis (812)

•Communication Improvement (603)

•Human Factors Engineering (279)

•Teamwork (302)

•Specialization of Care (150)

•Logistical Approaches (216)

•Culture of Safety (898)

•Technologic Approaches (391)

•Education and Training (784)

Clinical Areas

•Allied Health Services (12)

Target Audience

•Health Care Providers (1758)

•Health Care Executives and Administrators (2460)

•Non-Health Care Professionals (1654)

•Patients (252)

Setting of Care

•Hospitals (1592)

•Psychiatric Facilities (12)

•Residential Facilities (55)

•Ambulatory Care (189)

•Outpatient Surgery (25)

•Patient Transport (13)

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COMMENTARY classic

Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.

Gaba DM. Calif Manage Rev. 2000;43:1-20.

COMMENTARY classic

Risk mitigation in large scale systems: lessons from high reliability organizations.

Grabowski M, Roberts KH. Calif Manage Rev. 1997;39:152-162.

NEWSPAPER/MAGAZINE ARTICLE

A long way to go.

DerGurahian J. Mod Healthc. December 7, 2009.

COMMENTARY

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

Apold J, Quigley PA. J Nurs Care Qual. 2012;27:299-306.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

REVIEW

Improvements in the safety of patient care can help end the medical malpractice crisis in the United States.

Dalton GD, Samaropoulos XF, Dalton AC. Health Policy. 2008;86:153-162.

NEWSPAPER/MAGAZINE ARTICLE

The silent treatment: 'just be quiet about it'.

Smerd J. Workforce Management. November 19, 2007;1, 16-20.

COMMENTARY

Duty hour reform in a shifting medical landscape.

Jena AB, Prasad V. J Gen Intern Med. 2013 Apr 9; [Epub ahead of print].

STUDY

Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors.

Antiel RM, Van Arendonk KJ, Reed DA, et al. Arch Surg. 2012;147:536-541.

NEWSPAPER/MAGAZINE ARTICLE

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.

BOOK/REPORT classic

Safe Practices for Better Healthcare—2010 Update.

National Quality Forum. Washington, DC: National Quality Forum; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Plan aims to cut hospital deaths.

Appleby J. USA Today. June 6, 2005.

BOOK/REPORT

Addressing the quality and safety gap—parts I-II.

Princeton, NJ: Robert Wood Johnson Foundation; July 2009.

COMMENTARY

The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.

Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.

NEWSPAPER/MAGAZINE ARTICLE

Making hospitals accountable.

Peters PG Jr. Regulation. Summer 2009;32:30-36.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

PRESS RELEASE/ANNOUNCEMENT

AHA-NPSF Comprehensive Patient Safety Leadership Fellowship.

American Hospital Association, National Patient Safety Foundation.

BOOK/REPORT

Misadventures in Health Care: Inside Stories.

Bogner MS, ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2004. ISBN: 0805833781.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

NEWSPAPER/MAGAZINE ARTICLE

The impossible workload for doctors in training.

Chen PW. New York Times. April 18, 2013.

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