AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (242)

•Diagnostic Errors (304)

•Identification Errors (167)

•Discontinuities, Gaps, and Hand-Off Problems (793)

•Fatigue and Sleep Deprivation (140)

•Medication Safety (1847)

•Medical Complications (711)

•Nonsurgical Procedural Complications (133)

•Surgical Complications (762)

•Transfusion Complications (34)

•Psychological and Social Complications (218)

Origin/Sponsor

•Africa (9)

•Asia (98)

•Australia and New Zealand (170)

•Central and South America (14)

•Europe (741)

•North America (4843)

Resource Types

•Clinical Guideline (9)

•Journal Article (4369)

•Legislation/Regulation (75)

•Meeting/Conference (37)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (642)

•Press Release/Announcement (39)

•Special or Theme Issue (86)

•Tools/Toolkit (92)

•Web Resource (151)

•Grant (11)

Error Types

•Epidemiology of Errors and Adverse Events (1608)

•Active Errors (871)

•Latent Errors (382)

•Near Miss (104)

Approach to Improving Safety

•Quality Improvement Strategies (1451)

•Legal and Policy Approaches (596)

•Error Reporting and Analysis (1769)

•Communication Improvement (1410)

•Human Factors Engineering (750)

•Teamwork (467)

•Specialization of Care (397)

•Logistical Approaches (449)

•Culture of Safety (745)

•Technologic Approaches (1024)

•Education and Training (1129)

Clinical Areas

•Allied Health Services (14)

Target Audience

•Health Care Providers (4190)

•Health Care Executives and Administrators (4536)

•Non-Health Care Professionals (2112)

•Patients (512)

Setting of Care

•Hospitals (4014)

•Psychiatric Facilities (23)

•Residential Facilities (105)

•Ambulatory Care (593)

•Outpatient Surgery (66)

•Patient Transport (40)

1 - 20 of 5963

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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

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

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

Hospital discharge documentation and risk of rehospitalisation.

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

NEWSPAPER/MAGAZINE ARTICLE

Don't let a hospital make you sick.

Mishori R. Parade Magazine. February 8, 2009.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

BOOK/REPORT

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2009.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

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

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.

STUDY

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2013;39:213-220.

STUDY

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.

NEWSPAPER/MAGAZINE ARTICLE

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Injury and death associated with incidents reported to the Patient Safety Net.

Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.

STUDY

How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.

Hauck K, Zhao X. Med Care. 2011;49:1068-1075.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

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