AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (232)

•Diagnostic Errors (278)

•Identification Errors (175)

•Discontinuities, Gaps, and Hand-Off Problems (534)

•Fatigue and Sleep Deprivation (116)

•Medication Safety (1450)

•Medical Complications (644)

•Nonsurgical Procedural Complications (128)

•Surgical Complications (851)

•Transfusion Complications (27)

•Psychological and Social Complications (174)

Origin/Sponsor

•Africa (7)

•Asia (63)

•Australia and New Zealand (117)

•Central and South America (10)

•Europe (583)

•North America (4106)

Resource Types

•Clinical Guideline (11)

•Journal Article (3683)

•Legislation/Regulation (68)

•Meeting/Conference (31)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (482)

•Press Release/Announcement (34)

•Special or Theme Issue (75)

•Tools/Toolkit (74)

•Web Resource (129)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (1494)

•Active Errors (890)

•Latent Errors (310)

•Near Miss (98)

Approach to Improving Safety

•Quality Improvement Strategies (1232)

•Legal and Policy Approaches (481)

•Error Reporting and Analysis (1496)

•Communication Improvement (1163)

•Human Factors Engineering (663)

•Teamwork (409)

•Specialization of Care (302)

•Logistical Approaches (352)

•Culture of Safety (596)

•Technologic Approaches (828)

•Education and Training (940)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (3762)

•Health Care Executives and Administrators (3948)

•Non-Health Care Professionals (1740)

•Patients (421)

Setting of Care

•Hospitals (3116)

•Psychiatric Facilities (15)

•Residential Facilities (93)

•Ambulatory Care (469)

•Outpatient Surgery (71)

•Patient Transport (38)

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BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

NEWSPAPER/MAGAZINE ARTICLE

Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.

PA-PSRS Patient Saf Advis. September 2011;8:85-93.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

REVIEW

Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.

Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

STUDY

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

NEWSPAPER/MAGAZINE ARTICLE

How hepatitis probe led to clinic: old-fashioned legwork yielded clues that came together.

Allen M. Las Vegas Sun. March 2, 2008.

STUDY

The 80-hour work guidelines and resident survey perceptions of quality.

Biller CK, Antonacci AC, Pelletier S, et al. J Surg Res. 2006;135:275-281.

COMMENTARY

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

Manuel BM, Greenwald LM. Bull Am Coll Surg. March 2007;92:27-30.

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

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

The American College of Surgeons' closed claims study: new insights for improving care.

Griffen FD, Stephens LS, Alexander JB, et al. J Am Coll Surg. 2007;204:561-569.

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