AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (152)

•Diagnostic Errors (132)

•Identification Errors (99)

•Discontinuities, Gaps, and Hand-Off Problems (371)

•Fatigue and Sleep Deprivation (78)

•Medication Safety (1260)

•Medical Complications (402)

•Nonsurgical Procedural Complications (82)

•Surgical Complications (342)

•Transfusion Complications (18)

•Psychological and Social Complications (129)

Origin/Sponsor

•Africa (6)

•Asia (25)

•Australia and New Zealand (65)

•Central and South America (4)

•Europe (215)

•North America (3337)

Resource Types

•Clinical Guideline (6)

•Journal Article (2505)

•Legislation/Regulation (57)

•Meeting/Conference (42)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (433)

•Press Release/Announcement (31)

•Special or Theme Issue (69)

•Tools/Toolkit (62)

•Web Resource (131)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (757)

•Active Errors (496)

•Latent Errors (230)

•Near Miss (62)

Approach to Improving Safety

•Quality Improvement Strategies (966)

•Legal and Policy Approaches (443)

•Error Reporting and Analysis (1082)

•Communication Improvement (895)

•Human Factors Engineering (444)

•Teamwork (289)

•Specialization of Care (261)

•Logistical Approaches (241)

•Culture of Safety (594)

•Technologic Approaches (686)

•Education and Training (682)

Clinical Areas

•Allied Health Services (13)

Target Audience

•Health Care Providers (2957)

•Health Care Executives and Administrators (3069)

•Non-Health Care Professionals (1451)

•Patients (297)

Setting of Care

•Hospitals (2117)

•Psychiatric Facilities (17)

•Residential Facilities (75)

•Ambulatory Care (362)

•Outpatient Surgery (41)

•Patient Transport (33)

1 - 20 of 3705

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

COMMENTARY

A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

Iedema RA, Jorm C, Braithwaite J, Travaglia J, Lum M. Soc Sci Med. 2006;63:1201-1212.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:811, 815, 902.

STUDY

Using a bar-coded medication administration system to prevent medication errors in a community hospital network.

Sakowski J, Leonard T, Colburn S, et al. Am J Health Syst Pharm. 2005;62:2619-2625.

COMMENTARY

Root cause analysis.

Stecker MS. J Vasc Interv Radiol. 2007;18:5-8.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:547-550, 554.

STUDY

The nature and causes of unintended events reported at ten emergency departments.

Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. BMC Emerg Med. 2009;9:16.

STUDY

Patients' concerns about medical errors during hospitalization.

Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

NEWSPAPER/MAGAZINE ARTICLE classic

Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.

Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.

PRESS RELEASE/ANNOUNCEMENT

Patient controlled analgesia by proxy.

The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.

NEWSLETTER/JOURNAL

Sentinel Event Alert.

Oakbrook Terrace, IL: The Joint Commission.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Pediatric adverse drug events in the outpatient setting: an 11-year national analysis.

Bourgeois FT, Mandl KD, Valim C, Shannon MW. Pediatrics. 2009;124:e744-e750.

STUDY

The long road to patient safety: a status report on patient safety systems.

Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.

COMMENTARY

Kaiser Permanente's innovation on the front lines.

McCreary L. Harv Bus Rev. 2010;88:92, 94-7, 126.

BOOK/REPORT

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

STUDY

Resident fatigue: is there a patient safety issue?

Mitchell CD, Mooty CR, Dunn EL, Ramberger KC, Mangram AJ. Am J Surg. 2009;198:811-816.

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