AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (224)

•Diagnostic Errors (268)

•Identification Errors (151)

•Discontinuities, Gaps, and Hand-Off Problems (593)

•Fatigue and Sleep Deprivation (128)

•Medication Safety (1516)

•Medical Complications (611)

•Nonsurgical Procedural Complications (126)

•Surgical Complications (590)

•Transfusion Complications (31)

•Psychological and Social Complications (197)

Origin/Sponsor

•Africa (7)

•Asia (81)

•Australia and New Zealand (149)

•Central and South America (9)

•Europe (695)

•North America (4428)

Resource Types

•Clinical Guideline (9)

•Journal Article (4037)

•Legislation/Regulation (65)

•Meeting/Conference (40)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (499)

•Press Release/Announcement (36)

•Special or Theme Issue (83)

•Tools/Toolkit (73)

•Web Resource (146)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (1550)

•Active Errors (737)

•Latent Errors (319)

•Near Miss (99)

Approach to Improving Safety

•Quality Improvement Strategies (1406)

•Legal and Policy Approaches (541)

•Error Reporting and Analysis (1714)

•Communication Improvement (1217)

•Human Factors Engineering (648)

•Teamwork (446)

•Specialization of Care (333)

•Logistical Approaches (378)

•Culture of Safety (1000)

•Technologic Approaches (875)

•Education and Training (979)

Clinical Areas

•Allied Health Services (14)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (3859)

•Health Care Executives and Administrators (4420)

•Non-Health Care Professionals (2016)

•Patients (386)

Setting of Care

•Hospitals (3373)

•Psychiatric Facilities (21)

•Residential Facilities (97)

•Ambulatory Care (519)

•Outpatient Surgery (59)

•Patient Transport (37)

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STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

NEWSPAPER/MAGAZINE ARTICLE

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

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

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.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Inability of providers to predict unplanned readmissions.

Allaudeen N, Schnipper JL, Orav EJ, Wachter RM, Vidyarthi AR. J Gen Intern Med. 2011;26:771-776.

STUDY

A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.

Lander L, Roberson DW, Plummer KM, Forbes PW, Healy GB, Shah RK. Otolaryngol Head Neck Surg. 2010;143:480-486.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

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

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

Etchegaray JM, Thomas EJ. BMJ Qual Saf. 2012;21:490-498.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

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.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

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.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007.

Oakbrook Terrace, IL: The Joint Commission; November 2007.

COMMENTARY

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. Jt Comm J Qual Patient Saf. 2006;32:299-308.

STUDY

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.

López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

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