AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (224)

•Diagnostic Errors (141)

•Identification Errors (101)

•Discontinuities, Gaps, and Hand-Off Problems (321)

•Fatigue and Sleep Deprivation (79)

•Medication Safety (907)

•Medical Complications (318)

•Nonsurgical Procedural Complications (120)

•Surgical Complications (290)

•Transfusion Complications (14)

•Psychological and Social Complications (77)

Origin/Sponsor

•Africa (3)

•Asia (67)

•Australia and New Zealand (105)

•Central and South America (7)

•Europe (410)

•North America (2022)

Resource Types

•Audiovisual (19)

•Award (5)

•Book/Report (100)

•Clinical Guideline (4)

•Journal Article (2174)

•Legislation/Regulation (33)

•Meeting/Conference (9)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (235)

•Press Release/Announcement (27)

•Special or Theme Issue (35)

•Tools/Toolkit (26)

•Web Resource (32)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (673)

•Active Errors (716)

•Latent Errors (394)

•Near Miss (78)

Approach to Improving Safety

•Quality Improvement Strategies (629)

•Legal and Policy Approaches (179)

•Error Reporting and Analysis (803)

•Communication Improvement (583)

•Human Factors Engineering (512)

•Teamwork (199)

•Specialization of Care (158)

•Logistical Approaches (253)

•Culture of Safety (334)

•Technologic Approaches (472)

•Education and Training (486)

Clinical Areas

•Allied Health Services (7)

•Medicine (1771)

•Nursing (594)

•Pharmacy (277)

Target Audience

•Health Care Providers (1952)

•Health Care Executives and Administrators (2475)

•Non-Health Care Professionals (912)

•Patients (115)

Setting of Care

•Hospitals (1967)

•Psychiatric Facilities (13)

•Residential Facilities (46)

•Ambulatory Care (177)

•Outpatient Surgery (28)

•Patient Transport (18)

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STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

PRESS RELEASE/ANNOUNCEMENT

Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.

Rockville, MD: US Food and Drug Administration; November 9, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

REVIEW

Tubing misconnections: normalization of deviance.

Simmons D, Symes L, Guenter P, Graves K. Nutr Clin Pract. 2011;26:286-293.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

STUDY

The nurse's role in the causation of compensable injury.

Painter LM, Dudjak LA, Kidwell KM, Simmons RL, Kidwell RP. J Nurs Care Qual. 2011;4:311-319.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

STUDY

Hospital staff nurses' shift length associated with safety and quality of care.

Stimpfel AW, Aiken LH. J Nurs Care Qual. 2013;28:122-129.

COMMENTARY

Resuscitation Errors: A Shocking Problem

Abella BS, Edelson DP. AHRQ WebM&M [serial online]. July 2007.

STUDY

A case of mistaken identity: staff input on patient ID errors.

Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.

STUDY

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.

REVIEW

Inappropriate trust in technology: implications for critical care nurses.

Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.

STUDY

Expanding what we know about off-peak mortality in hospitals.

Hamilton P, Mathur S, Gemeinhardt G, Eschiti V, Campbell M. J Nurs Admin. 2010;40:124-128.

COMMENTARY

MRI suites: safety outside the bore.

Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.

COMMENTARY

The role of nursing surveillance in keeping patients safe.

Dresser S. J Nurs Adm. 2012;42:361-368.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

Bogdanich W. New York Times. January 24, 2010:A1.

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