AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (196)

•Diagnostic Errors (115)

•Identification Errors (77)

•Discontinuities, Gaps, and Hand-Off Problems (125)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (513)

•Medical Complications (163)

•Nonsurgical Procedural Complications (113)

•Surgical Complications (213)

•Transfusion Complications (9)

•Psychological and Social Complications (32)

Origin/Sponsor

•Africa (2)

•Asia (38)

•Australia and New Zealand (59)

•Central and South America (6)

•Europe (280)

•North America (1123)

Resource Types

•Audiovisual (16)

•Award (3)

•Book/Report (73)

•Clinical Guideline (3)

•Journal Article (1178)

•Legislation/Regulation (17)

•Meeting/Conference (11)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (141)

•Press Release/Announcement (31)

•Special or Theme Issue (32)

•Tools/Toolkit (16)

•Web Resource (40)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (408)

•Active Errors (539)

•Latent Errors (136)

•Near Miss (52)

Approach to Improving Safety

•Quality Improvement Strategies (594)

•Legal and Policy Approaches (130)

•Error Reporting and Analysis (503)

•Communication Improvement (295)

•Human Factors Engineering (367)

•Teamwork (120)

•Specialization of Care (64)

•Logistical Approaches (101)

•Culture of Safety (190)

•Technologic Approaches (269)

•Education and Training (430)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (1030)

•Health Care Executives and Administrators (1469)

•Non-Health Care Professionals (589)

•Patients (70)

Setting of Care

•Hospitals (914)

•Psychiatric Facilities (4)

•Residential Facilities (26)

•Ambulatory Care (110)

•Outpatient Surgery (24)

•Patient Transport (18)

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NEWSPAPER/MAGAZINE ARTICLE

ALERT: reports of severe harm after intravenous administration of breast milk to infants.

ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

Bogdanich W. New York Times. January 24, 2010:A1.

COMMENTARY

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

COMMENTARY

MRI suites: safety outside the bore.

Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.

ORGANIZATIONAL POLICY/GUIDELINES

Radiation risks of diagnostic imaging.

Sentinel Event Alert #47. August 24, 2011.

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

PRESS RELEASE/ANNOUNCEMENT

Relenza (zanamivir) inhalation powder.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

REVIEW

Inappropriate trust in technology: implications for critical care nurses.

Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.

PRESS RELEASE/ANNOUNCEMENT

CT brain perfusion scans safety investigation: initial notification.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

BOOK/REPORT

Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

Center for Devices and Radiological Health. Bethesda, MD: Food and Drug Administration, US Dept of Health and Human Services; 2006.

STUDY

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.

Valentin A, Capuzzo M, Guidet B, et al. Intensive Care Med. 2006;32:1591-1598.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing maternal death.

Sentinel Event Alert. January 26, 2010;(44):1-4.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

STUDY

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.

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