AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (174)

•Diagnostic Errors (200)

•Identification Errors (135)

•Discontinuities, Gaps, and Hand-Off Problems (450)

•Fatigue and Sleep Deprivation (83)

•Medication Safety (1405)

•Medical Complications (420)

•Nonsurgical Procedural Complications (92)

•Surgical Complications (419)

•Transfusion Complications (22)

•Psychological and Social Complications (143)

Origin/Sponsor

•Africa (5)

•Asia (33)

•Australia and New Zealand (81)

•Central and South America (5)

•Europe (309)

•North America (3652)

Resource Types

•Clinical Guideline (8)

•Journal Article (2714)

•Legislation/Regulation (64)

•Meeting/Conference (50)

•Newsletter/Journal (18)

•Newspaper/Magazine Article (544)

•Press Release/Announcement (46)

•Special or Theme Issue (73)

•Tools/Toolkit (79)

•Web Resource (146)

•Grant (13)

Error Types

•Epidemiology of Errors and Adverse Events (784)

•Active Errors (836)

•Latent Errors (451)

•Near Miss (121)

Approach to Improving Safety

•Quality Improvement Strategies (1070)

•Legal and Policy Approaches (530)

•Error Reporting and Analysis (1120)

•Communication Improvement (1058)

•Human Factors Engineering (554)

•Teamwork (312)

•Specialization of Care (268)

•Logistical Approaches (271)

•Culture of Safety (630)

•Technologic Approaches (785)

•Education and Training (790)

Clinical Areas

•Allied Health Services (19)

Target Audience

•Health Care Providers (3283)

•Health Care Executives and Administrators (3289)

•Non-Health Care Professionals (1610)

•Patients (424)

Setting of Care

•Hospitals (2331)

•Psychiatric Facilities (16)

•Residential Facilities (76)

•Ambulatory Care (429)

•Outpatient Surgery (43)

•Patient Transport (33)

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NEWSPAPER/MAGAZINE ARTICLE

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

FACT SHEET/FAQS classic

Preventing Medication Errors: A $21 Billion Opportunity.

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

NEWSPAPER/MAGAZINE ARTICLE

Fixing the medication reconciliation breakdown.

Starr D, West L. Most Wired Magazine. November 9, 2006.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

NEWSPAPER/MAGAZINE ARTICLE

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

NEWSPAPER/MAGAZINE ARTICLE

The five rights: a destination without a map.

ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.

DATABASE/DIRECTORY

Horsham, PA: Institute for Safe Medication Practices; 2011.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO tightens leash on medication reconciliation.

Perry LE. Drug Topics: Health-System Edition. March 20, 2006.

COMMENTARY

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

NEWSPAPER/MAGAZINE ARTICLE

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

GRANT RECIPIENT

The MacArthur Fellows Program: Michael Cohen.

The John D. and Catherine T. MacArthur Foundation. September 20, 2005.

FACT SHEET/FAQS

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

STUDY

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

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