AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (12)

•Diagnostic Errors (59)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (67)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (30)

•Medical Complications (10)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (35)

•Transfusion Complications (3)

•Psychological and Social Complications (14)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (5)

Resource Types

•Clinical Guideline (1)

•Journal Article (191)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (24)

•Press Release/Announcement (2)

•Special or Theme Issue (3)

•Tools/Toolkit (2)

•Web Resource (3)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (45)

•Active Errors (46)

•Latent Errors (18)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (65)

•Legal and Policy Approaches (18)

•Error Reporting and Analysis (68)

•Communication Improvement (147)

•Human Factors Engineering (19)

•Teamwork (38)

•Specialization of Care (20)

•Logistical Approaches (34)

•Culture of Safety (21)

•Technologic Approaches (29)

•Education and Training (54)

Clinical Areas

•Medicine (207)

•Nursing (19)

•Pharmacy (11)

Target Audience

•Health Care Providers (234)

•Health Care Executives and Administrators (158)

•Non-Health Care Professionals (70)

•Patients (13)

Setting of Care

•Hospitals (128)

•Ambulatory Care (14)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 243

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REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

STUDY

Errors in a stat laboratory: changes in type and frequency since 1996.

Carraro P, Plebani M. Clin Chem. 2007;53:1338-42.

TOOLKIT

Communicating Critical Test Results.

Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

STUDY

Finding blunders in thyroid testing: experience in newborns.

Zilka LJ, Lott JA, Baker LC, Linard SM. J Clin Lab Anal. 2008;22:254-256.

BOOK/REPORT

Why Current Breast Pathology Practices Must Be Evaluated.

Dallas, TX: Susan G. Komen Breast Cancer Foundation; June 2006.

STUDY

Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods.

Raab SS, Andrew-Jaja C, Condel JL, Dabbs DJ. Am J Obstet Gynecol. 2006;194:57-64.

STUDY

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

Tsai JJ, Yeun JY, Kumar VA, Don BR. Am J Kidney Dis. 2005;46:820-829.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

STUDY

CT for suspected appendicitis in children: an analysis of diagnostic errors.

Taylor GA, Callahan MJ, Rodriguez D, Smink DS. Pediatr Radiol. 2006;36:331-337.

SPECIAL OR THEME ISSUE

Communicating critical test results.

Jt Comm J Qual Patient Saf. 2005;31(special issue).

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

STUDY

Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology.

Renshaw AA, Gould EW. Am J Clin Pathol. 2006;125:820-822.

STUDY

Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.

Raab SS, Grzybicki DM, Janosky JE, et al. Cancer. 2005;104:2205-2213.

STUDY

Failure to notify reportable test results: significance in medical malpractice.

Gale BD, Bissett-Siegel DP, Davidson SJ, Juran DC. J Am Coll Radiol. 2011;8:776-779.

COMMENTARY

PCA Overdose

Doyle DJ. AHRQ WebM&M [serial online]. July/August 2005.

BOOK/REPORT

Silence Kills: The Seven Crucial Conversations for Healthcare.

Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. VitalSmarts; 2005.E45

BOOK/REPORT

The Rebecca O'Malley Report.

Cork, Ireland: Health Information and Quality Authority; March 21, 2008.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

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