AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (157)

•Identification Errors (46)

•Discontinuities, Gaps, and Hand-Off Problems (188)

•Fatigue and Sleep Deprivation (65)

•Medication Safety (459)

•Medical Complications (93)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (228)

•Transfusion Complications (5)

•Psychological and Social Complications (238)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (20)

•Europe (70)

•North America (1723)

Resource Types

•Audiovisual (26)

•Award (4)

•Book/Report (76)

•Clinical Guideline (5)

•Journal Article (1352)

•Legislation/Regulation (26)

•Meeting/Conference (5)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (259)

•Press Release/Announcement (5)

•Special or Theme Issue (16)

•Tools/Toolkit (29)

•Web Resource (34)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (409)

•Active Errors (236)

•Latent Errors (80)

•Near Miss (31)

Approach to Improving Safety

•Quality Improvement Strategies (370)

•Legal and Policy Approaches (214)

•Error Reporting and Analysis (904)

•Communication Improvement (591)

•Human Factors Engineering (115)

•Teamwork (114)

•Specialization of Care (71)

•Logistical Approaches (135)

•Culture of Safety (169)

•Technologic Approaches (229)

•Education and Training (356)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1480)

•Health Care Executives and Administrators (1170)

•Non-Health Care Professionals (589)

•Patients (213)

Setting of Care

•Hospitals (928)

•Psychiatric Facilities (1)

•Residential Facilities (15)

•Ambulatory Care (183)

•Outpatient Surgery (15)

•Patient Transport (5)

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STUDY

Patients' concerns about medical errors during hospitalization.

Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.

NEWSPAPER/MAGAZINE ARTICLE

When doctors say, "We're sorry."

Eisenberg D. Time Magazine. August 15, 2005;166:50.

COMMENTARY

Apologies and medical error.

Robbennolt JK. Clin Orthop Relat Res. 2009;467:376-382.

REVIEW

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors.

Kaldjian LC, Jones EW, Rosenthal GE, Tripp-Reimer T, Hillis SL. J Gen Intern Med. 2006;21:942-948.

COMMENTARY

Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.

Taylor D, Hassan MA, Luterman A, Rodning CB. Arch Surg. 2008;143:87-92.

REVIEW

Narrative review: do state laws make it easier to say "I'm sorry?"

McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

COMMENTARY

The art of apology: when and how to seek forgiveness.

Roberts RG. Fam Pract Manag. July/August 2007;14:44-49.

REVIEW

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life.

Weiner JS, Roth J. J Palliat Med. 2006;9:451-463.

COMMENTARY

Apology for errors: whose responsibility?

Leape LL. Front Health Serv Manage. 2012;28:3-12.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

STUDY

How patients perceive a doctor's caring attitude.

Quirk M, Mazor K, Haley H-L, et al. Patient Educ Couns. 2008;72:359-366.

AUDIOVISUAL

Removing Insult from Injury: Disclosing Adverse Events.

Baltimore, MD: Johns Hopkins Bloomberg School of Public Health; 2005.

STUDY

The role of talking (and keeping silent) in physician coping with medical error: a qualitative study.

May N, Plews-Ogan M. Patient Educ Couns. 2012;88:449-454.

STUDY

Wisdom through adversity: learning and growing in the wake of an error.

Plews-Ogan M, Owens JE, May NB. Patient Educ Couns. 2013;91:236-242.

REVIEW

Ethical and practical aspects of disclosing adverse events in the emergency department.

Stokes SL, Wu AW, Pronovost PJ. Emerg Med Clin North Am. 2006;24:703-714.

AUDIOVISUAL PRESENTATION

Physician, say you're sorry.

Delbanco T, Bell SK. New York Times Video. November 24, 2008.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

STUDY

Patients' and physicians' attitudes regarding the disclosure of medical errors.

Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. JAMA. 2003;289:1001-1007.

AUDIOVISUAL

It's time to say sorry.

Coombes R. BMJ Podcast. June 1, 2012.

STUDY

How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting.

Witman AB, Park DM, Hardin SB. Arch Intern Med. 1996;156:2565-2569.

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