AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (189)

•Diagnostic Errors (214)

•Identification Errors (122)

•Discontinuities, Gaps, and Hand-Off Problems (751)

•Fatigue and Sleep Deprivation (117)

•Medication Safety (1305)

•Medical Complications (543)

•Nonsurgical Procedural Complications (95)

•Surgical Complications (449)

•Transfusion Complications (23)

•Psychological and Social Complications (188)

Origin/Sponsor

•Africa (6)

•Asia (37)

•Australia and New Zealand (113)

•Central and South America (5)

•Europe (403)

•North America (4206)

Resource Types

•Clinical Guideline (9)

•Journal Article (3307)

•Legislation/Regulation (73)

•Meeting/Conference (44)

•Newsletter/Journal (15)

•Newspaper/Magazine Article (589)

•Press Release/Announcement (31)

•Special or Theme Issue (78)

•Tools/Toolkit (92)

•Web Resource (151)

•Grant (15)

Error Types

•Epidemiology of Errors and Adverse Events (936)

•Active Errors (631)

•Latent Errors (317)

•Near Miss (75)

Approach to Improving Safety

•Quality Improvement Strategies (1204)

•Legal and Policy Approaches (592)

•Error Reporting and Analysis (1308)

•Communication Improvement (1389)

•Human Factors Engineering (555)

•Teamwork (427)

•Specialization of Care (342)

•Logistical Approaches (375)

•Culture of Safety (743)

•Technologic Approaches (856)

•Education and Training (934)

Clinical Areas

•Allied Health Services (18)

Target Audience

•Health Care Providers (3558)

•Health Care Executives and Administrators (3791)

•Non-Health Care Professionals (1818)

•Patients (460)

Setting of Care

•Hospitals (3177)

•Psychiatric Facilities (25)

•Residential Facilities (123)

•Ambulatory Care (502)

•Outpatient Surgery (51)

•Patient Transport (37)

1 - 20 of 4851

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NEWSPAPER/MAGAZINE ARTICLE

Approved: no new National Patient Safety Goals, only minor revisions for 2011.

Jt Comm Perspect. August 2010;30:6-7.

SPECIAL OR THEME ISSUE

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

REVIEW

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

NEWSPAPER/MAGAZINE ARTICLE

Approved: 2010 National Patient Safety Goals.

Jt Comm Perspect. October 2009;29:1, 20-31.

STUDY

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

STUDY

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.

Ward KT, Bates-Jensen B, Eslami MS, et al. Am J Geriatr Pharmacother. 2008;6:205-211.

PRESS RELEASE/ANNOUNCEMENT

Patient safety: healthcare acquired conditions and serious reportable events.

Washington, DC: National Quality Forum; September 2009.

NEWSPAPER/MAGAZINE ARTICLE

USP initiatives for the safe use of medical gases.

Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.

SPECIAL OR THEME ISSUE

Clinical Handover: Critical Communications.

Med J Aust. 2009;190:S105-S160.

NEWSPAPER/MAGAZINE ARTICLE

Survive your doctor.

Holt TE. Men's Health. November 3, 2006.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

NEWSPAPER/MAGAZINE ARTICLE

Preventing fatal errors.

Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.

STUDY

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

Weinberg DB, Gittell JH, Lusenhop RW, Kautz CM, Wright J. Health Serv Res. 2007;42:7-24.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

AWARD RECIPIENT

Building and sustaining a systemwide culture of safety.

Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke G, Merti GE. Jt Comm J Qual Patient Saf. 2005;31:684-689.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

COMMENTARY

Assessing hospital safety on nights and weekends: the SWAN tool.

Shulkin DJ. J Patient Saf. 2009;5:75-78.

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