AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (153)

•Diagnostic Errors (183)

•Identification Errors (100)

•Discontinuities, Gaps, and Hand-Off Problems (499)

•Fatigue and Sleep Deprivation (136)

•Medication Safety (1085)

•Medical Complications (419)

•Nonsurgical Procedural Complications (72)

•Surgical Complications (371)

•Transfusion Complications (18)

•Psychological and Social Complications (166)

Origin/Sponsor

•Africa (2)

•Asia (40)

•Australia and New Zealand (65)

•Central and South America (3)

•Europe (239)

•North America (3680)

Resource Types

•Clinical Guideline (8)

•Journal Article (2835)

•Legislation/Regulation (56)

•Meeting/Conference (28)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (563)

•Press Release/Announcement (22)

•Special or Theme Issue (64)

•Tools/Toolkit (67)

•Web Resource (96)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (726)

•Active Errors (444)

•Latent Errors (242)

•Near Miss (57)

Approach to Improving Safety

•Quality Improvement Strategies (1059)

•Legal and Policy Approaches (517)

•Error Reporting and Analysis (1151)

•Communication Improvement (906)

•Human Factors Engineering (409)

•Teamwork (292)

•Specialization of Care (271)

•Logistical Approaches (402)

•Culture of Safety (637)

•Technologic Approaches (704)

•Education and Training (754)

Clinical Areas

•Allied Health Services (10)

Target Audience

•Health Care Providers (2935)

•Health Care Executives and Administrators (3197)

•Non-Health Care Professionals (1458)

•Patients (370)

Setting of Care

•Hospitals (2823)

•Psychiatric Facilities (13)

•Residential Facilities (59)

•Ambulatory Care (289)

•Outpatient Surgery (36)

•Patient Transport (14)

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COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

Patient safety concerns arising from test results that return after hospital discharge.

Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

STUDY

Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods.

Raab SS, Andrew-Jaja C, Condel JL, Dabbs DJ. Am J Obstet Gynecol. 2006;194:57-64.

NEWSPAPER/MAGAZINE ARTICLE

Error rate greatest in hospital radiology.

Stein R. The Washington Post. January 18, 2006:A03.

STUDY

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

Ott LK, Pinsky MR, Hoffman LA, et al. BMJ Qual Saf. 2012 Mar 2; [Epup ahead of print].

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

STUDY

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units.

Vogus TJ, Sutcliffe KM. Med Care. 2007;45:46-54.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

BOOK/REPORT

Recommendations for Safe Use of Insulin in Hospitals.

Bethesda, MD: American Society of Health-System Pharmacists; 2006.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

NEWSPAPER/MAGAZINE ARTICLE

Building a case for medication reconciliation.

Nurse Advise-ERR. April 2006;4:1-3.

COMMENTARY

Best-practice protocols: Preventing adverse drug events.

Weir VL. Nurs Manage. 2005;36:24-30.

ORGANIZATIONAL POLICY/GUIDELINES

Tubing misconnections—a persistent and potentially deadly occurrence.

Sentinel Event Alert. April 3, 2006;(36):1-3.

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

"I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care.

Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. Arch Intern Med. 2004;164:2223-2228.

ORGANIZATIONAL POLICY/GUIDELINES

2008 Recommendations for Pre-Anesthesia Checkout Procedures.

ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.

COMMENTARY

An unsuspected MR projectile: a "wooden" chair with metal bracing.

Ulaner GA, Colletti PM. J Magn Reson Imaging. 2006;23:781-782.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

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