AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (127)

•Diagnostic Errors (101)

•Identification Errors (42)

•Discontinuities, Gaps, and Hand-Off Problems (564)

•Fatigue and Sleep Deprivation (67)

•Medication Safety (614)

•Medical Complications (411)

•Nonsurgical Procedural Complications (33)

•Surgical Complications (143)

•Transfusion Complications (16)

•Psychological and Social Complications (79)

Origin/Sponsor

•Australia and New Zealand (92)

•Central and South America (5)

•Europe (364)

•North America (1817)

Resource Types

•Audiovisual (22)

•Book/Report (141)

•Clinical Guideline (2)

•Journal Article (1777)

•Legislation/Regulation (19)

•Meeting/Conference (13)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (229)

•Press Release/Announcement (6)

•Special or Theme Issue (34)

•Tools/Toolkit (39)

•Web Resource (50)

Error Types

•Epidemiology of Errors and Adverse Events (636)

•Active Errors (332)

•Latent Errors (175)

•Near Miss (37)

Approach to Improving Safety

•Quality Improvement Strategies (581)

•Legal and Policy Approaches (227)

•Error Reporting and Analysis (634)

•Communication Improvement (687)

•Human Factors Engineering (268)

•Teamwork (194)

•Specialization of Care (231)

•Logistical Approaches (206)

•Culture of Safety (376)

•Technologic Approaches (397)

•Education and Training (413)

Clinical Areas

•Allied Health Services (4)

•Medicine (2168)

•Nursing (170)

•Pharmacy (177)

Target Audience

•Health Care Providers (1581)

•Health Care Executives and Administrators (1918)

•Non-Health Care Professionals (838)

•Patients (183)

Setting of Care

•Hospitals (1967)

•Psychiatric Facilities (9)

•Residential Facilities (38)

•Ambulatory Care (226)

•Outpatient Surgery (13)

•Patient Transport (22)

1 - 20 of 2349

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STUDY

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers.

Li P, Stelfox HT, Ghali WA. Am J Med. 2011;124:860-867.

COMMENTARY

Check the Bags.

Caldwell M, Dracup KA. AHRQ WebM&M [serial online]. September 2003.

REVIEW

The efficacy of computer-enabled discharge communication interventions: a systematic review.

Motamedi SM, Posadas-Calleja J, Straus S, et al. BMJ Qual Saf. 2011;20:403-415.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

COMMENTARY

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.

Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I. Acad Med. 2012;87:411-418.

STUDY

classic

Information exchange among physicians caring for the same patient in the community.

van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.

COMMENTARY

Central Line Clot.

Randolph AG. AHRQ WebM&M [serial online]. May 2003.

STUDY

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

van Walraven C, Jennings A, Taljaard M, et al. CMAJ. 2011;183:E1067-E1072.

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.

COMMENTARY

Crushing Chest Pain: A Missed Opportunity.

Graber M. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Code Status Confusion.

Lo B, Tulsky JA. AHRQ WebM&M [serial online]. July 2003.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.

BOOK/REPORT

Patient Safety in Primary Care.

Kingston-Riechers J, Ospina M, Jonsson E, Childs P, McLeod L, Maxted JM. Edmondton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541273.

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 multifaceted program for improving quality of care in intensive care units: IATROREF study.

Garrouste-Orgeas M, Soufir L, Tabah A, et al; Outcomerea Study Group. Crit Care Med. 2012;40:468-476.

COMMENTARY

Handovers from the OR to the ICU.

Bonifacio AS, Segall N, Barbeito A, Taekman J, Schroeder R, Mark JB. Int Anesthesiol Clin. 2013;51:43-61.

STUDY

Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency.

Thomas AN, Panchagnula U. Anaesthesia. 2008;63:726-733.

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