AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (176)

•Diagnostic Errors (212)

•Identification Errors (90)

•Discontinuities, Gaps, and Hand-Off Problems (654)

•Fatigue and Sleep Deprivation (84)

•Medication Safety (909)

•Medical Complications (483)

•Nonsurgical Procedural Complications (80)

•Surgical Complications (279)

•Transfusion Complications (19)

•Psychological and Social Complications (134)

Origin/Sponsor

•Africa (9)

•Asia (54)

•Australia and New Zealand (148)

•Central and South America (9)

•Europe (491)

•North America (2739)

Resource Types

•Clinical Guideline (6)

•Journal Article (2415)

•Legislation/Regulation (55)

•Meeting/Conference (33)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (402)

•Press Release/Announcement (41)

•Special or Theme Issue (66)

•Tools/Toolkit (64)

•Web Resource (123)

•Grant (13)

Error Types

•Epidemiology of Errors and Adverse Events (681)

•Active Errors (586)

•Latent Errors (417)

•Near Miss (58)

Approach to Improving Safety

•Quality Improvement Strategies (916)

•Legal and Policy Approaches (504)

•Error Reporting and Analysis (949)

•Communication Improvement (990)

•Human Factors Engineering (458)

•Teamwork (367)

•Specialization of Care (315)

•Logistical Approaches (343)

•Culture of Safety (579)

•Technologic Approaches (557)

•Education and Training (888)

Clinical Areas

•Allied Health Services (14)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (2713)

•Health Care Executives and Administrators (2943)

•Non-Health Care Professionals (1396)

•Patients (301)

Setting of Care

•Hospitals (2602)

•Psychiatric Facilities (31)

•Residential Facilities (64)

•Ambulatory Care (275)

•Outpatient Surgery (30)

•Patient Transport (40)

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STUDY

'August is always a nightmare': results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey.

Vaughan L, McAlister G, Bell D. Clin Med. 2011;11:322-326.

COMMENTARY

Do Not Disturb!

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

COMMENTARY

When “Psychiatric” Symptoms are Not.

Goldberg RJ. AHRQ WebM&M [serial online]. February 2003.

REVIEW

Inpatient suicide: preventing a common sentinel event.

Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.

COMMENTARY

Back to Basics

Hellman R. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Suicidal Man with Gun.

Simon RI. AHRQ WebM&M [serial online]. May 2003.

COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

MULTI-USE WEBSITE

Safer Sign Out.

Emergency Medicine Patient Safety Foundation.

BOOK/REPORT

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

Thomson R, Luettel D, Healey F, Scobie S. London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634055.

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

COMMENTARY

Triage Time Bomb.

Washington DL. AHRQ WebM&M [serial online]. January 2004.

BOOK/REPORT classic

Advances in Patient Safety: From Research to Implementation.

Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

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.

REVIEW

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

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