AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (156)

•Diagnostic Errors (119)

•Identification Errors (90)

•Discontinuities, Gaps, and Hand-Off Problems (378)

•Fatigue and Sleep Deprivation (102)

•Medication Safety (935)

•Medical Complications (455)

•Nonsurgical Procedural Complications (68)

•Surgical Complications (311)

•Transfusion Complications (15)

•Psychological and Social Complications (154)

Origin/Sponsor

•Africa (4)

•Asia (29)

•Australia and New Zealand (59)

•Central and South America (4)

•Europe (243)

•North America (3443)

Resource Types

•Clinical Guideline (4)

•Journal Article (2271)

•Legislation/Regulation (64)

•Meeting/Conference (38)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (685)

•Press Release/Announcement (25)

•Special or Theme Issue (69)

•Tools/Toolkit (76)

•Web Resource (129)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (601)

•Active Errors (403)

•Latent Errors (255)

•Near Miss (46)

Approach to Improving Safety

•Quality Improvement Strategies (998)

•Legal and Policy Approaches (655)

•Error Reporting and Analysis (1132)

•Communication Improvement (844)

•Human Factors Engineering (395)

•Teamwork (296)

•Specialization of Care (253)

•Logistical Approaches (277)

•Culture of Safety (933)

•Technologic Approaches (604)

•Education and Training (735)

Clinical Areas

•Allied Health Services (12)

Target Audience

•Health Care Providers (2266)

•Health Care Executives and Administrators (2963)

•Non-Health Care Professionals (1603)

•Patients (688)

Setting of Care

•Hospitals (2629)

•Psychiatric Facilities (16)

•Residential Facilities (67)

•Ambulatory Care (264)

•Outpatient Surgery (41)

•Patient Transport (16)

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NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

BOOK/REPORT

The First Annual HealthGrades Pediatric Patient Safety in American Hospitals Study.

Reed K, May R. Golden, CO: Health Grades, Inc; 2010.

BOOK/REPORT classic

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.

London, England: The Stationery Office; July 2001.

STUDY

Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation.

Frankel A, Grillo SP, Baker EG, et al. Jt Comm J Qual Patient Saf. 2005;31:423-437.

AUDIOVISUAL

Eye to eye: Donald Berwick.

"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.

BOOK/REPORT

How Safe Is Your Hospital?

Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.

NEWSPAPER/MAGAZINE ARTICLE

Preventing fatal errors.

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

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

NEWSPAPER/MAGAZINE ARTICLE

Guideline is skirted on obesity surgeries.

Kowalczyk L. The Boston Globe. December 22, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Sarasota Memorial Hospital reviewed after restrained patient dies.

Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.

AUDIOVISUAL

Good News: How Hospitals Heal Themselves [documentary].

Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.

MULTI-USE WEBSITE

MHA Keystone Center for Patient Safety and Quality.

Michigan Health and Hospital Association.

STUDY

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.

Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals save money, but safety is questioned.

Klein A. The Washington Post. December 11, 2005:A01.

COMMENTARY classic

Risk mitigation in large scale systems: lessons from high reliability organizations.

Grabowski M, Roberts KH. Calif Manage Rev. 1997;39:152-162.

BOOK/REPORT classic

Josie's Story.

King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.

STUDY

Stories from the sharp end: case studies in safety improvement.

McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.

BOOK/REPORT

HealthGrades Seventh Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; March 2010.

NEWSPAPER/MAGAZINE ARTICLE

Report: hospital errors cost 18 lives.

Rojas-Burke J. Oregonian. January 30, 2007:B01.

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