AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (140)

•Diagnostic Errors (147)

•Identification Errors (104)

•Discontinuities, Gaps, and Hand-Off Problems (440)

•Fatigue and Sleep Deprivation (86)

•Medication Safety (924)

•Medical Complications (402)

•Nonsurgical Procedural Complications (75)

•Surgical Complications (440)

•Transfusion Complications (17)

•Psychological and Social Complications (291)

Origin/Sponsor

•Africa (5)

•Asia (26)

•Australia and New Zealand (95)

•Central and South America (3)

•Europe (335)

•North America (3421)

Resource Types

•Clinical Guideline (6)

•Journal Article (2703)

•Legislation/Regulation (57)

•Meeting/Conference (45)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (440)

•Press Release/Announcement (26)

•Special or Theme Issue (75)

•Tools/Toolkit (64)

•Web Resource (132)

•Grant (13)

Error Types

•Epidemiology of Errors and Adverse Events (665)

•Active Errors (488)

•Latent Errors (235)

•Near Miss (65)

Approach to Improving Safety

•Quality Improvement Strategies (991)

•Legal and Policy Approaches (476)

•Error Reporting and Analysis (1051)

•Communication Improvement (1204)

•Human Factors Engineering (463)

•Teamwork (553)

•Specialization of Care (258)

•Logistical Approaches (275)

•Culture of Safety (719)

•Technologic Approaches (635)

•Education and Training (799)

Clinical Areas

•Allied Health Services (18)

Target Audience

•Health Care Providers (3058)

•Health Care Executives and Administrators (3275)

•Non-Health Care Professionals (1766)

•Patients (314)

Setting of Care

•Hospitals (2260)

•Psychiatric Facilities (16)

•Residential Facilities (67)

•Ambulatory Care (339)

•Outpatient Surgery (38)

•Patient Transport (31)

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STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

REVIEW

Intimidation: a concept analysis.

Lamontagne C. Nurs Forum. 2010;45:54-65.

STUDY

Incidence and impact of physician and nurse disruptive behaviors in the emergency department.

Rosenstein AH, Naylor B. J Emerg Med. 2012;43:139-148.

STUDY

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

COMMENTARY

Danger in Disruption

Fontaine DK. AHRQ WebM&M [serial online]. October 2009.

STUDY

Role of medical students in preventing patient harm and enhancing patient safety.

Seiden SC, Galvan C, Lamm R. Qual Saf Health Care. 2006;15:272-276.

STUDY

Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US.

Baldwin DC Jr, Daugherty SR. J Interprof Care. 2008;22:573-586.

COMMENTARY

Do Not Disturb!

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

STUDY

Teamwork on inpatient medical units: assessing attitudes and barriers.

O'Leary KJ, Ritter CD, Wheeler H, Szekendi MK, Brinton TS, Williams MV. Qual Saf Health Care. 2010;19:117-121.

STUDY

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.

STUDY

Managing disruptive behaviors in the health care setting: focus on obstetrics services.

Rosenstein AH. Am J Obstet Gynecol. 2011;204:187-192.

SPECIAL OR THEME ISSUE

2009 Doctor-Nurse Behavior Survey.

Physician Exec. Nov-Dec 2009;5-22.

STUDY

Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.

Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.

STUDY

Physician perspectives on quality and error in the outpatient setting.

Manwell LB, Williams ES, Babbott S, Rabatin JS, Linzer M. WMJ. 2009;108:139-144.

NEWSPAPER/MAGAZINE ARTICLE

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

STUDY

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.

Braithwaite J, Westbrook MT, Robinson M, Michael S, Pirone C, Robinson P. BMJ Qual Saf. 2011;20:424-431.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Disruptive physicians.

Sandrick K. Trustee. November 2009.

COMMENTARY

Difficult Encounters: A CMO and CNO Respond

Ring EJ, Hirsch JE. AHRQ WebM&M [serial online]. October 2009.

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