AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (181)

•Diagnostic Errors (193)

•Identification Errors (124)

•Discontinuities, Gaps, and Hand-Off Problems (525)

•Fatigue and Sleep Deprivation (98)

•Medication Safety (1236)

•Medical Complications (618)

•Nonsurgical Procedural Complications (101)

•Surgical Complications (380)

•Transfusion Complications (24)

•Psychological and Social Complications (152)

Origin/Sponsor

•Australia and New Zealand (83)

•Central and South America (4)

•Europe (358)

•North America (3709)

Resource Types

•Audiovisual (60)

•Bibliography (2)

•Book/Report (273)

•Clinical Guideline (9)

•Journal Article (2939)

•Legislation/Regulation (62)

•Meeting/Conference (34)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (522)

•Press Release/Announcement (25)

•Special or Theme Issue (65)

•Tools/Toolkit (71)

•Web Resource (114)

Error Types

•Epidemiology of Errors and Adverse Events (916)

•Active Errors (680)

•Latent Errors (305)

•Near Miss (73)

Approach to Improving Safety

•Quality Improvement Strategies (1032)

•Legal and Policy Approaches (463)

•Error Reporting and Analysis (1139)

•Communication Improvement (1044)

•Human Factors Engineering (698)

•Teamwork (321)

•Specialization of Care (316)

•Logistical Approaches (346)

•Culture of Safety (582)

•Technologic Approaches (743)

•Education and Training (811)

Clinical Areas

•Allied Health Services (9)

•Dentistry (2)

•Medicine (2921)

•Nursing (314)

•Pharmacy (483)

Target Audience

•Health Care Providers (3127)

•Health Care Executives and Administrators (3141)

•Non-Health Care Professionals (1521)

•Patients (405)

Setting of Care

•Hospitals (3095)

•Psychiatric Facilities (19)

•Residential Facilities (68)

•Ambulatory Care (429)

•Outpatient Surgery (36)

•Patient Transport (22)

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STUDY

The cost of pneumonia after acute stroke.

Katzan IL, Dawson NV, Thomas CL, Votruba ME, Cebul RD. Neurology. 2007;68:1938-1943.

NEWSPAPER/MAGAZINE ARTICLE

Smart pump custom concentrations without hard "low concentration" alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

STUDY

The association between night or weekend admission and hospitalization-relevant patient outcomes.

Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. J Hosp Med. 2011;6:10-14.

STUDY

Using Lean to improve medication administration safety: in search of the "perfect dose."

Ching JM, Long C, Williams BL, Blackmore CC. Jt Comm J Qual Patient Saf. 2013;39:195-204.

NEWSPAPER/MAGAZINE ARTICLE

CMS seeks to add 9 hospital-acquired conditions to no-pay list.

O'Reilly KB. American Medical News. May 12, 2008.

STUDY

Perceptions of hospital safety climate and incidence of readmission.

Hansen LO, Williams MV, Singer SJ. Health Serv Res. 2011;46:596-616.

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

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

Wetterneck TB, Walker JM, Blosky MA, et al. J Am Med Inform Assoc. 2011;18:774-782.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

STUDY

Physician implicit review to identify preventable errors during in-hospital cardiac arrest.

Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.

COMMENTARY

Complementary telephone strategies to improve postdischarge communication.

Rennke S, Kesh S, Neeman N, Sehgal NL. Am J Med. 2012;125:28-30.

COMMENTARY

Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child.

Wilson BL. J Spec Pediatr Nurs. 2010;15:84-87.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

COMMENTARY

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

STUDY

classic

Preventing patient harms through systems of care.

Pronovost PJ, Bo-Linn GW. JAMA. 2012;308:769-770.

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