AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (212)

•Diagnostic Errors (241)

•Identification Errors (149)

•Discontinuities, Gaps, and Hand-Off Problems (599)

•Fatigue and Sleep Deprivation (122)

•Medication Safety (1435)

•Medical Complications (671)

•Nonsurgical Procedural Complications (133)

•Surgical Complications (538)

•Transfusion Complications (34)

•Psychological and Social Complications (200)

Origin/Sponsor

•Australia and New Zealand (129)

•Central and South America (7)

•Europe (582)

•North America (4416)

Resource Types

•Audiovisual (58)

•Bibliography (2)

•Book/Report (317)

•Clinical Guideline (10)

•Journal Article (3797)

•Legislation/Regulation (72)

•Meeting/Conference (39)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (568)

•Press Release/Announcement (31)

•Special or Theme Issue (86)

•Tools/Toolkit (81)

•Web Resource (149)

Error Types

•Epidemiology of Errors and Adverse Events (1147)

•Active Errors (748)

•Latent Errors (341)

•Near Miss (91)

Approach to Improving Safety

•Quality Improvement Strategies (1310)

•Legal and Policy Approaches (533)

•Error Reporting and Analysis (1531)

•Communication Improvement (1240)

•Human Factors Engineering (659)

•Teamwork (458)

•Specialization of Care (373)

•Logistical Approaches (395)

•Culture of Safety (994)

•Technologic Approaches (887)

•Education and Training (1026)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

•Dentistry (7)

•Medicine (3515)

•Nursing (444)

•Pharmacy (524)

Target Audience

•Health Care Providers (3759)

•Health Care Executives and Administrators (4197)

•Non-Health Care Professionals (1981)

•Patients (439)

Setting of Care

•Hospitals (3603)

•Psychiatric Facilities (21)

•Residential Facilities (90)

•Ambulatory Care (493)

•Outpatient Surgery (51)

•Patient Transport (36)

1 - 20 of 5279

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STUDY

Physician implicit review to identify preventable errors during in-hospital cardiac arrest.

Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

COMMENTARY

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

Melnyk BM. Nurs Adm Q. 2012;36:127-135.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

COMMENTARY

Complementary telephone strategies to improve postdischarge communication.

Rennke S, Kesh S, Neeman N, Sehgal NL. Am J Med. 2012;125:28-30.

BOOK/REPORT

The Patient Safety Leadership WalkRounds Guide.

Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

STUDY

Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation.

Benning A, Ghaleb M, Suokas A, et al. BMJ. 2011;342:d195.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

COMMENTARY

Integrating CUSP and TRIP to improve patient safety.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety front and center.

Terry K. Hosp Health Netw. July 2011;85:38-40, 42.

COMMENTARY

The role of nursing surveillance in keeping patients safe.

Dresser S. J Nurs Adm. 2012;42:361-368.

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