AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (196)

•Diagnostic Errors (165)

•Identification Errors (134)

•Discontinuities, Gaps, and Hand-Off Problems (550)

•Fatigue and Sleep Deprivation (112)

•Medication Safety (1541)

•Medical Complications (497)

•Nonsurgical Procedural Complications (103)

•Surgical Complications (462)

•Transfusion Complications (22)

•Psychological and Social Complications (152)

Origin/Sponsor

•Africa (1)

•Asia (61)

•Australia and New Zealand (107)

•Central and South America (6)

•Europe (404)

•North America (3927)

Resource Types

•Audiovisual (48)

•Award (31)

•Book/Report (217)

•Clinical Guideline (10)

•Journal Article (3350)

•Legislation/Regulation (62)

•Meeting/Conference (29)

•Newsletter/Journal (9)

•Newspaper/Magazine Article (551)

•Press Release/Announcement (19)

•Special or Theme Issue (71)

•Tools/Toolkit (67)

•Web Resource (90)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (943)

•Active Errors (632)

•Latent Errors (299)

•Near Miss (84)

Approach to Improving Safety

•Quality Improvement Strategies (1112)

•Legal and Policy Approaches (418)

•Error Reporting and Analysis (1176)

•Communication Improvement (1098)

•Human Factors Engineering (607)

•Teamwork (497)

•Specialization of Care (320)

•Logistical Approaches (387)

•Culture of Safety (647)

•Technologic Approaches (1061)

•Education and Training (1025)

Clinical Areas

•Allied Health Services (12)

Target Audience

•Health Care Providers (3080)

•Health Care Executives and Administrators (3703)

•Non-Health Care Professionals (1816)

•Patients (329)

Setting of Care

•Hospitals (3162)

•Psychiatric Facilities (17)

•Residential Facilities (79)

•Ambulatory Care (378)

•Outpatient Surgery (37)

•Patient Transport (23)

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STUDY

Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean.

Schoville RR. J Nurs Care Qual. 2009;24:316-324.

STUDY

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety.

Kutney-Lee A, Kelly D. J Nurs Adm. 2011;41:466-472.

STUDY

Nurse decision making in the prearrest period.

Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.

REVIEW

Fall prevention in hospitals: an integrative review.

Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

COMMENTARY

A model for developing high-reliability teams.

Riley W, Davis SE, Miller KK, McCullough M. J Nurs Manag. 2010;18:556-563.

STUDY

Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care.

McAlearney AS, Vrontos J Jr, Schneider PJ, Curran CR, Czerwinski BS, Pedersen CA. J Patient Saf. 2007;3:75-81.

COMMENTARY

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

Tessier EG, Henneman EA, Nathanson B, Plotkin K, Heelon M. Am J Health Syst Pharm. 2010;67:607-611.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

REVIEW

Nurses' role in medication safety.

Choo J, Hutchinson A, Bucknall T. J Nurs Manag. 2010;18:853-861.

STUDY

Barriers and facilitators to nursing handoffs: recommendations for redesign.

Welsh CA, Flanagan ME, Ebright P. Nurs Outlook. 2010;58:148-154.

STUDY

How RNs rescue patients: a qualitative study of RNs' perceived involvement in rapid response teams.

Leach LS, Mayo A, O'Rourke M. Qual Saf Health Care. 2010;19:e13.

SPECIAL OR THEME ISSUE

Nurses Transforming Care.

Am J Nurs. 2009;109(suppl 11):3-80, C3.

COMMENTARY

Implementing AORN recommended practices for medication safety.

Hicks RW, Wanzer LJ, Denholm B. AORN J. 2012;96:605-622.

STUDY

Patient safety, quality care, and service utilization with PLATO (Physician Leadership for Accurate and Timely Orders): a pilot study.

Brunt BA, Gifford IL. J Nurses Staff Dev. 2009;25:E11-E18.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

COMMENTARY

Framework for patient safety—part 1 and part 2.

Blouin AS, McDonagh KJ. J Nurs Adm. 2011;41:397-400, 450-452.

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