AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (237)

•Diagnostic Errors (253)

•Identification Errors (146)

•Discontinuities, Gaps, and Hand-Off Problems (544)

•Fatigue and Sleep Deprivation (102)

•Medication Safety (1457)

•Medical Complications (674)

•Nonsurgical Procedural Complications (130)

•Surgical Complications (601)

•Transfusion Complications (29)

•Psychological and Social Complications (175)

Origin/Sponsor

•Africa (7)

•Asia (64)

•Australia and New Zealand (139)

•Central and South America (11)

•Europe (631)

•North America (4300)

Resource Types

•Clinical Guideline (9)

•Journal Article (3852)

•Legislation/Regulation (65)

•Meeting/Conference (42)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (456)

•Press Release/Announcement (36)

•Special or Theme Issue (100)

•Tools/Toolkit (68)

•Web Resource (156)

•Grant (16)

Error Types

•Epidemiology of Errors and Adverse Events (1500)

•Active Errors (726)

•Latent Errors (298)

•Near Miss (90)

Approach to Improving Safety

•Quality Improvement Strategies (1452)

•Legal and Policy Approaches (481)

•Error Reporting and Analysis (1593)

•Communication Improvement (1186)

•Human Factors Engineering (658)

•Teamwork (555)

•Specialization of Care (349)

•Logistical Approaches (351)

•Culture of Safety (975)

•Technologic Approaches (827)

•Education and Training (943)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (3799)

•Health Care Executives and Administrators (4229)

•Non-Health Care Professionals (1924)

•Patients (352)

Setting of Care

•Hospitals (3180)

•Psychiatric Facilities (18)

•Residential Facilities (93)

•Ambulatory Care (456)

•Outpatient Surgery (58)

•Patient Transport (40)

1 - 20 of 5215

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STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

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.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

STUDY

Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.

Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007.

Burton DC, Edwards JR, Horan TC, Jernigan JA, Fridkin SK. JAMA. 2009;301:727-736.

STUDY

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

Vigorito MC, McNicoll L, Adams L, Sexton B. Jt Comm J Qual Patient Saf. 2011;37:509-514.

STUDY

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

STUDY

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.

Longmate AG, Ellis KS, Boyle L, et al. BMJ Qual Saf. 2011;20:174-180.

STUDY

Explaining Michigan: developing an ex post theory of a quality improvement program.

Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

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