AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (189)

•Diagnostic Errors (221)

•Identification Errors (138)

•Discontinuities, Gaps, and Hand-Off Problems (519)

•Fatigue and Sleep Deprivation (96)

•Medication Safety (1555)

•Medical Complications (455)

•Nonsurgical Procedural Complications (90)

•Surgical Complications (417)

•Transfusion Complications (28)

•Psychological and Social Complications (136)

Origin/Sponsor

•Australia and New Zealand (88)

•Central and South America (8)

•Europe (354)

•North America (3594)

Resource Types

•Audiovisual (60)

•Book/Report (194)

•Clinical Guideline (8)

•Journal Article (3055)

•Legislation/Regulation (52)

•Meeting/Conference (18)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (567)

•Press Release/Announcement (15)

•Special or Theme Issue (38)

•Tools/Toolkit (58)

•Web Resource (75)

Error Types

•Epidemiology of Errors and Adverse Events (1415)

•Active Errors (844)

•Latent Errors (450)

•Near Miss (94)

Approach to Improving Safety

•Quality Improvement Strategies (951)

•Legal and Policy Approaches (407)

•Error Reporting and Analysis (1416)

•Communication Improvement (919)

•Human Factors Engineering (493)

•Teamwork (248)

•Specialization of Care (272)

•Logistical Approaches (352)

•Culture of Safety (527)

•Technologic Approaches (737)

•Education and Training (713)

Clinical Areas

•Allied Health Services (17)

•Dentistry (2)

•Medicine (2756)

•Nursing (665)

•Pharmacy (587)

Target Audience

•Health Care Providers (2852)

•Health Care Executives and Administrators (3111)

•Non-Health Care Professionals (1335)

•Patients (383)

Setting of Care

•Hospitals (3032)

•Psychiatric Facilities (16)

•Residential Facilities (84)

•Ambulatory Care (406)

•Outpatient Surgery (44)

•Patient Transport (29)

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COMMENTARY

Implementing AORN recommended practices for medication safety.

Hicks RW, Wanzer LJ, Denholm B. AORN J. 2012;96:605-622.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

COMMENTARY

ISMP medication error report analysis.

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

REVIEW

The effect of nurse staffing patterns on medical errors and nurse burnout.

Garrett C. AORN J. 2008;87:1191-1192, 1194, 1196-1200, 1202-1204.

REVIEW

A concept analysis of situational awareness in nursing.

Fore AM, Sculli GL. J Adv Nurs. 2013 Mar 25; [Epub ahead of print].

STUDY

Nurses relate the contributing factors involved in medication errors.

Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. J Clin Nurs. 2007;16:447-457.

STUDY

The rate and costs attributable to intravenous patient-controlled analgesia errors.

Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

NEWSPAPER/MAGAZINE ARTICLE

Barcode technology flaws put some patients at risk.

US News & World Report. July 3, 2008.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

STUDY

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

Holden RJ, Scanlon MC, Patel NR, et al. BMJ Qual Saf. 2011;20:15-24.

STUDY

A case of mistaken identity: staff input on patient ID errors.

Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.

STUDY

Nurse staffing, burnout, and health care–associated infection.

Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Am J Infect Control. 2012;40:486-490.

STUDY

The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement.

Spence Laschinger HK, Leiter MP. J Nurs Adm. 2006;36:259-267.

NEWSPAPER/MAGAZINE ARTICLE

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4.

STUDY

Factors influencing perioperative nurses' error reporting preferences.

Espin S, Regehr G, Levinson W, Baker GR, Biancucci C, Lingard L. AORN J. 2007;85:527-528, 530-532, 534-536, 539-543.

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

STUDY

It's always something: hospital nurses managing risk.

Groves PS, Finfgeld-Connett D, Wakefield BJ. Clin Nurs Res. 2012 Dec 4; [Epub ahead of print].

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