AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (186)

•Diagnostic Errors (204)

•Identification Errors (141)

•Discontinuities, Gaps, and Hand-Off Problems (541)

•Fatigue and Sleep Deprivation (100)

•Medication Safety (1448)

•Medical Complications (461)

•Nonsurgical Procedural Complications (110)

•Surgical Complications (493)

•Transfusion Complications (25)

•Psychological and Social Complications (203)

Origin/Sponsor

•Africa (5)

•Asia (83)

•Australia and New Zealand (167)

•Central and South America (7)

•Europe (713)

•North America (3279)

Resource Types

•Audiovisual (40)

•Award (29)

•Book/Report (235)

•Clinical Guideline (6)

•Journal Article (3277)

•Legislation/Regulation (69)

•Meeting/Conference (28)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (402)

•Press Release/Announcement (44)

•Special or Theme Issue (74)

•Tools/Toolkit (72)

•Web Resource (110)

•Grant (11)

Error Types

•Epidemiology of Errors and Adverse Events (978)

•Active Errors (698)

•Latent Errors (447)

•Near Miss (81)

Approach to Improving Safety

•Quality Improvement Strategies (1059)

•Legal and Policy Approaches (416)

•Error Reporting and Analysis (1285)

•Communication Improvement (1163)

•Human Factors Engineering (632)

•Teamwork (511)

•Specialization of Care (294)

•Logistical Approaches (311)

•Culture of Safety (607)

•Technologic Approaches (937)

•Education and Training (795)

Clinical Areas

•Allied Health Services (14)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (3281)

•Health Care Executives and Administrators (3736)

•Non-Health Care Professionals (1893)

•Patients (277)

Setting of Care

•Hospitals (2936)

•Psychiatric Facilities (15)

•Residential Facilities (80)

•Ambulatory Care (408)

•Outpatient Surgery (44)

•Patient Transport (29)

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COMMENTARY

Mitigating error vulnerability at the transition of care through the use of health IT applications.

Cortelyou-Ward K, Swain A, Yeung T. J Med Syst. 2012;36:3825-3831.

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

Murphy K. New York Times. October 31, 2006:F5.

COMMENTARY classic

Fixing healthcare from the inside, today.

Spear SJ. Harv Bus Rev. September 2005;83:78-91.

STUDY

Hospital rules-based system: the next generation of medical informatics for patient safety.

Wilson JW, Oyen LJ, Ou NN, et al. Am J Health Syst Pharm. 2005;62:499-505.

COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

NEWSPAPER/MAGAZINE ARTICLE

Our long journey towards a safety-minded just culture. Part II: where we're going.

ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.

STUDY

Insufficient communication about medication use at the interface between hospital and primary care.

Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

SPECIAL OR THEME ISSUE

Patient Safety Papers.

Baker GR, ed. Healthc Q. 2005;8:1-156.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

COMMENTARY

Danger in Disruption

Fontaine DK. AHRQ WebM&M [serial online]. October 2009.

REVIEW

Overriding of drug safety alerts in computerized physician order entry.

van der Sijs H, Aarts J, Vulto A, Berg M. J Am Med Inform Assoc. 2006;13:138-147.

COMMENTARY

Patient safety in an interprofessional learning environment.

Horsburgh M, Merry AF, Seddon M. Med Educ. 2005;39:512-513.

COMMENTARY

Passing the "Yo' Mama" test.

Blair R. Health Manage Tech. June 2006;27:16.

COMMENTARY

Using portable digital technology for clinical care and critical incidents: a new model.

Bolsin SN, Faunce T, Colson M. Aust Health Rev. 2005;29:297-305.

REVIEW

What is patient safety culture? A review of the literature.

Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. J Nurs Scholarsh. 2010;42:156-165.

BOOK/REPORT

Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.

Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.

COMMENTARY

Flying Object Hits MRI.

Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.

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