AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (165)

•Diagnostic Errors (217)

•Identification Errors (101)

•Discontinuities, Gaps, and Hand-Off Problems (704)

•Fatigue and Sleep Deprivation (122)

•Medication Safety (962)

•Medical Complications (353)

•Nonsurgical Procedural Complications (86)

•Surgical Complications (416)

•Transfusion Complications (11)

•Psychological and Social Complications (117)

Origin/Sponsor

•Africa (2)

•Asia (23)

•Australia and New Zealand (70)

•Central and South America (5)

•Europe (234)

•North America (2976)

Resource Types

•Audiovisual (31)

•Award (10)

•Book/Report (90)

•Clinical Guideline (8)

•Journal Article (2677)

•Legislation/Regulation (47)

•Meeting/Conference (13)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (344)

•Press Release/Announcement (15)

•Special or Theme Issue (35)

•Tools/Toolkit (34)

•Web Resource (57)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (755)

•Active Errors (587)

•Latent Errors (390)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (773)

•Legal and Policy Approaches (252)

•Error Reporting and Analysis (889)

•Communication Improvement (903)

•Human Factors Engineering (461)

•Teamwork (295)

•Specialization of Care (274)

•Logistical Approaches (315)

•Culture of Safety (380)

•Technologic Approaches (577)

•Education and Training (673)

Clinical Areas

•Allied Health Services (12)

Target Audience

•Health Care Providers (2559)

•Health Care Executives and Administrators (2691)

•Non-Health Care Professionals (1126)

•Patients (189)

Setting of Care

•Hospitals (2198)

•Psychiatric Facilities (7)

•Residential Facilities (47)

•Ambulatory Care (266)

•Outpatient Surgery (30)

•Patient Transport (29)

1 - 20 of 3371

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STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

STUDY

Who's covering our loved ones: surprising barriers in the sign-out process.

Antonoff MB, Berdan EA, Kirchner VA, et al. Am J Surg. 2013;205:77-84.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

Hess DR, Tokarczyk A, O’Malley M, Gavaghan S, Sullivan J, Schmidt U. Chest. 2010;138:1475-1479.

STUDY

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.

STUDY

Checklists change communication about key elements of patient care.

Newkirk M, Pamplin JC, Kuwamoto R, Allen DA, Chung KK. J Trauma Acute Care Surg. 2012;73(2 suppl 1):S75-S82.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

COMMENTARY

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Pastores SM, O’Connor MF, Kleinpell RM, et al. Crit Care Med. 2011;39:2540-2549.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

COMMENTARY

Deciphering the Code

Goldstein MK. AHRQ WebM&M [serial online]. Febuary 2006.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

STUDY

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. J Hosp Med. 2011;6:68-72.

STUDY

ED handoffs: observed practices and communication errors.

Maughan BC, Lei L, Cydulka RK. Am J Emerg Med. 2011;29:502-511.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.

Droogh JM, Kruger HL, Ligtenberg JJM, Zijlstra JG. Jt Comm J Qual Patient Saf. 2012;38:554-559.

COMMENTARY

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

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