AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (212)

•Diagnostic Errors (228)

•Identification Errors (143)

•Discontinuities, Gaps, and Hand-Off Problems (581)

•Fatigue and Sleep Deprivation (119)

•Medication Safety (1399)

•Medical Complications (656)

•Nonsurgical Procedural Complications (123)

•Surgical Complications (501)

•Transfusion Complications (31)

•Psychological and Social Complications (185)

Origin/Sponsor

•Africa (6)

•Asia (61)

•Australia and New Zealand (118)

•Central and South America (7)

•Europe (511)

•North America (4218)

Resource Types

•Clinical Guideline (9)

•Journal Article (3573)

•Legislation/Regulation (70)

•Meeting/Conference (33)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (553)

•Press Release/Announcement (34)

•Special or Theme Issue (66)

•Tools/Toolkit (77)

•Web Resource (133)

•Grant (17)

Error Types

•Epidemiology of Errors and Adverse Events (1120)

•Active Errors (722)

•Latent Errors (318)

•Near Miss (85)

Approach to Improving Safety

•Quality Improvement Strategies (1228)

•Legal and Policy Approaches (530)

•Error Reporting and Analysis (1424)

•Communication Improvement (1169)

•Human Factors Engineering (624)

•Teamwork (399)

•Specialization of Care (349)

•Logistical Approaches (379)

•Culture of Safety (676)

•Technologic Approaches (863)

•Education and Training (955)

Clinical Areas

•Allied Health Services (10)

Target Audience

•Health Care Providers (3588)

•Health Care Executives and Administrators (3962)

•Non-Health Care Professionals (1843)

•Patients (432)

Setting of Care

•Hospitals (3494)

•Psychiatric Facilities (19)

•Residential Facilities (82)

•Ambulatory Care (474)

•Outpatient Surgery (51)

•Patient Transport (30)

1 - 20 of 4973

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MULTI-USE WEBSITE

On the CUSP: Stop HAI.

Health Research & Educational Trust, MHA Keystone Center.

STUDY

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.

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.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

BOOK/REPORT

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

PRESS RELEASE/ANNOUNCEMENT

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

Oakbrook Terrace, IL: Joint Commission; May 17, 2011.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

STUDY

Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.

Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Ann Intern Med. 2012;157:305-312.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

STUDY

Practically speaking: rethinking hand hygiene improvement programs in health care settings.

Son C, Chuck T, Childers T, et al. Am J Infect Control. 2011;39:716-724.

COMMENTARY

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

COMMENTARY

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

Duval-Arnould J, Mathews SC, Weeks K, et al. Jt Comm J Qual Patient Saf. 2012;38:41-47.

AUDIOVISUAL

Battling hospital-acquired infections.

Gross T. "Fresh Air." National Public Radio. January 9, 2008.

STUDY

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

White CM, Statile AM, Conway PH, et al. Pediatrics. 2012;129:e1042-e1050.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

BOOK/REPORT

2011 National and State Healthcare–Associated Infections Standardized Infection Ratio Report.

Malpiedi PJ, Peterson KD, Soe MM, et al. Atlanta, GA: Centers for Disease Control and Prevention; February 11, 2013.

TOOLKIT

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

Washington, DC: US Department of Health and Human Services; May 2011.

STUDY

The interrelationship of isolation precautions and adverse events in an acute care facility.

Spence MR, McQuaid M. Am J Infect Control. 2011;39:154-155.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.

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