AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (212)

•Diagnostic Errors (357)

•Identification Errors (171)

•Discontinuities, Gaps, and Hand-Off Problems (546)

•Fatigue and Sleep Deprivation (114)

•Medication Safety (1315)

•Medical Complications (511)

•Nonsurgical Procedural Complications (125)

•Surgical Complications (834)

•Transfusion Complications (30)

•Psychological and Social Complications (173)

Origin/Sponsor

•Africa (4)

•Asia (57)

•Australia and New Zealand (110)

•Central and South America (11)

•Europe (493)

•North America (3944)

Resource Types

•Clinical Guideline (9)

•Journal Article (3439)

•Legislation/Regulation (62)

•Meeting/Conference (37)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (477)

•Press Release/Announcement (35)

•Special or Theme Issue (90)

•Tools/Toolkit (65)

•Web Resource (124)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (1052)

•Active Errors (940)

•Latent Errors (328)

•Near Miss (93)

Approach to Improving Safety

•Quality Improvement Strategies (1120)

•Legal and Policy Approaches (444)

•Error Reporting and Analysis (1330)

•Communication Improvement (1159)

•Human Factors Engineering (819)

•Teamwork (410)

•Specialization of Care (267)

•Logistical Approaches (359)

•Culture of Safety (555)

•Technologic Approaches (799)

•Education and Training (929)

Clinical Areas

•Allied Health Services (13)

Target Audience

•Health Care Providers (3630)

•Health Care Executives and Administrators (3740)

•Non-Health Care Professionals (1682)

•Patients (399)

Setting of Care

•Hospitals (2831)

•Psychiatric Facilities (15)

•Residential Facilities (72)

•Ambulatory Care (425)

•Outpatient Surgery (61)

•Patient Transport (36)

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COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

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.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

STUDY

The value of inking breast cores to reduce specimen mix-up.

Renshaw AA, Kish R, Gould EW. Am J Clin Pathol. February 2007;127:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

COMMENTARY

Incomplete care—on the trail of flaws in the system.

Gandhi TK, Zuccotti G, Lee TH. N Engl J Med. 2011;365:486-488.

MEETING/CONFERENCE PROCEEDINGS

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

STUDY

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Surgery. 2006;140:25-33.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

STUDY

Classifying laboratory incident reports to identify problems that jeopardize patient safety.

Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Am J Clin Pathol. 2003;120:18-26.

MULTI-USE WEBSITE

The Final Check: Say it Out Loud.

Plano, TX: Outcome Engenuity; July 2012.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Errors of diagnosis in pediatric practice: a multisite survey.

Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

COMMENTARY

Critical diagnoses (critical values) in anatomic pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:982-984.

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

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