AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (117)

•Diagnostic Errors (198)

•Identification Errors (130)

•Discontinuities, Gaps, and Hand-Off Problems (225)

•Fatigue and Sleep Deprivation (17)

•Medication Safety (806)

•Medical Complications (213)

•Nonsurgical Procedural Complications (51)

•Surgical Complications (277)

•Transfusion Complications (15)

•Psychological and Social Complications (59)

Origin/Sponsor

•Africa (5)

•Asia (43)

•Australia and New Zealand (81)

•Central and South America (8)

•Europe (353)

•North America (1449)

Resource Types

•Audiovisual (23)

•Award (5)

•Book/Report (92)

•Clinical Guideline (3)

•Journal Article (1558)

•Legislation/Regulation (22)

•Meeting/Conference (13)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (189)

•Press Release/Announcement (28)

•Special or Theme Issue (14)

•Tools/Toolkit (23)

•Web Resource (41)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (979)

•Active Errors (734)

•Latent Errors (367)

•Near Miss (73)

Approach to Improving Safety

•Quality Improvement Strategies (548)

•Legal and Policy Approaches (183)

•Error Reporting and Analysis (813)

•Communication Improvement (500)

•Human Factors Engineering (299)

•Teamwork (99)

•Specialization of Care (99)

•Logistical Approaches (108)

•Culture of Safety (202)

•Technologic Approaches (391)

•Education and Training (359)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (1732)

•Health Care Executives and Administrators (1549)

•Non-Health Care Professionals (675)

•Patients (177)

Setting of Care

•Hospitals (1249)

•Psychiatric Facilities (9)

•Residential Facilities (47)

•Ambulatory Care (262)

•Outpatient Surgery (31)

•Patient Transport (27)

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COMMENTARY

Failure to Report

Spath PL. AHRQ WebM&M [serial online]. March 2007.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Error tracking in a clinical biochemistry laboratory.

Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

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

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

COMMENTARY

Internally-developed online adverse drug reaction and medication error reporting systems.

Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.

STUDY

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

FACT SHEET/FAQS

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

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