AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (195)

•Diagnostic Errors (206)

•Identification Errors (155)

•Discontinuities, Gaps, and Hand-Off Problems (465)

•Fatigue and Sleep Deprivation (107)

•Medication Safety (1206)

•Medical Complications (502)

•Nonsurgical Procedural Complications (97)

•Surgical Complications (840)

•Transfusion Complications (25)

•Psychological and Social Complications (165)

Origin/Sponsor

•Africa (7)

•Asia (42)

•Australia and New Zealand (108)

•Central and South America (6)

•Europe (473)

•North America (3928)

Resource Types

•Clinical Guideline (7)

•Journal Article (3236)

•Legislation/Regulation (72)

•Meeting/Conference (49)

•Newsletter/Journal (16)

•Newspaper/Magazine Article (495)

•Press Release/Announcement (32)

•Special or Theme Issue (81)

•Tools/Toolkit (69)

•Web Resource (150)

•Grant (13)

Error Types

•Epidemiology of Errors and Adverse Events (1380)

•Active Errors (600)

•Latent Errors (245)

•Near Miss (82)

Approach to Improving Safety

•Quality Improvement Strategies (1136)

•Legal and Policy Approaches (616)

•Error Reporting and Analysis (1380)

•Communication Improvement (1076)

•Human Factors Engineering (558)

•Teamwork (398)

•Specialization of Care (288)

•Logistical Approaches (312)

•Culture of Safety (679)

•Technologic Approaches (747)

•Education and Training (860)

Clinical Areas

•Allied Health Services (14)

Target Audience

•Health Care Providers (3508)

•Health Care Executives and Administrators (3688)

•Non-Health Care Professionals (1833)

•Patients (405)

Setting of Care

•Hospitals (2820)

•Psychiatric Facilities (18)

•Residential Facilities (82)

•Ambulatory Care (398)

•Outpatient Surgery (66)

•Patient Transport (37)

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STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

STUDY

The "July phenomenon": is trauma the exception?

Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC. J Am Coll Surg. 2009;209:378-384.

STUDY

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

Lightdale JR, Mahoney LB, Fredette ME, Valim C, Wong S, DiNardo JA. J Perianesth Nurs. 2009;24:300-306.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

MULTI-USE WEBSITE

Safe Surgery 2015.

Harvard School of Public Health.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.

COMMENTARY

JCAHO's National Patient Safety Goals 2006.

Catalano K. J Perianesth Nurs. February 2006;21:6-11.

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

Sharing lessons learned to prevent incorrect surgery.

Neily J, Mills PD, Paull DE, et al. Am Surg. 2012;78:1276-1280.

STUDY

Relationship between occurrence of surgical complications and hospital finances.

Eappen S, Lane BH, Rosenberg B, et al. JAMA. 2013;309:1599-1606.

COMMENTARY

The increased incidence of anesthetic adverse events in late afternoon surgeries.

Johnson J. AORN J. 2008;88:79-87.

STUDY

Adverse events during hospitalization: results of a patient survey.

Fowler FJ, Epstein A, Weingart SN, et al. Jt Comm J Qual Patient Saf. 2008;34:583-590.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.

NEWSPAPER/MAGAZINE ARTICLE

Challenges ahead in technology training: a report on the training initiative of the Committee on Technology.

Olympio MA, Reinke B, Abramovich A. APSF Newsletter. Fall 2006;21:43-48.

COMMENTARY

Language barriers to health care in the United States.

Flores G. N Engl J Med. 2006;355:229-231.

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