AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (145)

•Diagnostic Errors (168)

•Identification Errors (94)

•Discontinuities, Gaps, and Hand-Off Problems (373)

•Fatigue and Sleep Deprivation (79)

•Medication Safety (962)

•Medical Complications (402)

•Nonsurgical Procedural Complications (84)

•Surgical Complications (379)

•Transfusion Complications (21)

•Psychological and Social Complications (133)

Origin/Sponsor

•Africa (4)

•Asia (24)

•Australia and New Zealand (71)

•Central and South America (4)

•Europe (255)

•North America (3391)

Resource Types

•Clinical Guideline (6)

•Journal Article (2574)

•Legislation/Regulation (54)

•Meeting/Conference (47)

•Newsletter/Journal (15)

•Newspaper/Magazine Article (395)

•Press Release/Announcement (30)

•Special or Theme Issue (78)

•Tools/Toolkit (66)

•Web Resource (143)

•Grant (14)

Error Types

•Epidemiology of Errors and Adverse Events (782)

•Active Errors (439)

•Latent Errors (213)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (1159)

•Legal and Policy Approaches (477)

•Error Reporting and Analysis (1297)

•Communication Improvement (848)

•Human Factors Engineering (417)

•Teamwork (310)

•Specialization of Care (235)

•Logistical Approaches (238)

•Culture of Safety (629)

•Technologic Approaches (604)

•Education and Training (669)

Clinical Areas

•Allied Health Services (14)

Target Audience

•Health Care Providers (2919)

•Health Care Executives and Administrators (3197)

•Non-Health Care Professionals (1491)

•Patients (289)

Setting of Care

•Hospitals (2127)

•Psychiatric Facilities (14)

•Residential Facilities (72)

•Ambulatory Care (341)

•Outpatient Surgery (42)

•Patient Transport (32)

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NEWSPAPER/MAGAZINE ARTICLE

Health literacy—a quality and patient safety imperative.

Foubister V. Quality Matters. November/December 2006.

COMMENTARY classic

What practices will most improve safety? Evidence-based medicine meets patient safety.

Leape LL, Berwick DM, Bates DW. JAMA. 2002;288:501-507.

MULTI-USE WEBSITE

Medical Event Data Collection and Analysis Service (MEDCAS).

Cognitive Technologies Laboratory, University of Chicago.

NEWSPAPER/MAGAZINE ARTICLE

Studies on medical errors warrant a second opinion.

Bialik C. The Wall Street Journal Online. June 29, 2006.

BOOK/REPORT

Compendium 2000-2005.

Washington, DC: National Quality Forum; 2006. ISBN: 1933875003.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

REVIEW

The impact of declining clinical autopsy: need for revised healthcare policy.

Xiao J, Krueger GR, Buja LM, Covinsky M. Am J Med Sci. 2009;337:41-46.

BOOK/REPORT

Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.

Davis K, Schoen S, Schoenbaum SC, et al. New York, NY: The Commonwealth Fund; April 2006.

NEWSPAPER/MAGAZINE ARTICLE

Health for life. Keys to safer hospitals.

Berwick DM. Newsweek. December 12, 2005;46:75-78.

BOOK/REPORT classic

Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.

Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.

STUDY

Measuring errors and adverse events in health care.

Thomas EJ, Petersen LA. J Gen Intern Med. 2003;18:61-67.

COMMENTARY

Monitoring patient safety in health care: building the case for surrogate measures.

Gaynes RP, Platt R. Jt Comm J Qual Patient Saf. 2006;32:95-101.

NEWSPAPER/MAGAZINE ARTICLE

Health-care industry agrees on patient safety rules.

Landro L. Wall Street Journal (Eastern Edition). November 1, 2006:D1. [reprinted on Post-gazette.com].

COMMENTARY

Assessing hospital safety on nights and weekends: the SWAN tool.

Shulkin DJ. J Patient Saf. 2009;5:75-78.

AWARD RECIPIENT

2010 John M. Eisenberg Patient Safety and Quality Award Recipients.

The Joint Commission. January 12, 2011.

DATABASE/DIRECTORY

MEDMARX®.

Rockville, MD: U.S. Pharmacopeia; 2011.

STUDY

Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.

Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, Brem H, Quiñones-Hinojosa A. Arch Surg. 2011;146:226-232.

MULTI-USE WEBSITE

Indiana Medical Error Reporting System.

Indiana State Department of Health.

COMMENTARY

Advancing nursing home quality through quality improvement itself.

Werner RM, Konetzka RT. Health Aff (Millwood). 2010;29:81-86.

STUDY

A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. J Surg Res. 2009;153:95-104.

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