AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (190)

•Diagnostic Errors (165)

•Identification Errors (100)

•Discontinuities, Gaps, and Hand-Off Problems (327)

•Fatigue and Sleep Deprivation (42)

•Medication Safety (938)

•Medical Complications (512)

•Nonsurgical Procedural Complications (80)

•Surgical Complications (374)

•Transfusion Complications (18)

•Psychological and Social Complications (57)

Origin/Sponsor

•Africa (5)

•Asia (54)

•Australia and New Zealand (120)

•Central and South America (10)

•Europe (502)

•North America (2064)

Resource Types

•Audiovisual (12)

•Award (11)

•Book/Report (128)

•Clinical Guideline (5)

•Journal Article (2305)

•Legislation/Regulation (36)

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•Newspaper/Magazine Article (150)

•Press Release/Announcement (18)

•Special or Theme Issue (36)

•Tools/Toolkit (23)

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•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (1201)

•Active Errors (515)

•Latent Errors (176)

•Near Miss (62)

Approach to Improving Safety

•Quality Improvement Strategies (705)

•Legal and Policy Approaches (165)

•Error Reporting and Analysis (833)

•Communication Improvement (630)

•Human Factors Engineering (457)

•Teamwork (229)

•Specialization of Care (235)

•Logistical Approaches (182)

•Culture of Safety (310)

•Technologic Approaches (768)

•Education and Training (470)

Clinical Areas

•Allied Health Services (8)

Target Audience

•Health Care Providers (2233)

•Health Care Executives and Administrators (2455)

•Non-Health Care Professionals (1123)

•Patients (133)

Setting of Care

•Hospitals (1916)

•Psychiatric Facilities (11)

•Residential Facilities (50)

•Ambulatory Care (262)

•Outpatient Surgery (31)

•Patient Transport (28)

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STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.

Longmate AG, Ellis KS, Boyle L, et al. BMJ Qual Saf. 2011;20:174-180.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

STUDY

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

STUDY

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

PRESS RELEASE/ANNOUNCEMENT classic

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

PRESS RELEASE/ANNOUNCEMENT

10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs.

Rockville, MD: Agency for Healthcare Research and Quality; February 19, 2009.

STUDY

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.

BOOK/REPORT

Eliminating CLABSI: A National Patient Safety Imperative.

Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.

STUDY

Intervention to reduce transmission of resistant bacteria in intensive care.

Huskins WC, Huckabee CM, O'Grady NP, et al; STAR*ICU Trial Investigators. N Engl J Med. 2011;364:1407-1418.

COMMENTARY classic

Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

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