AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (104)

•Diagnostic Errors (11)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (12)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (81)

•Medical Complications (43)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (31)

•Transfusion Complications (5)

•Psychological and Social Complications (3)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (7)

Resource Types

•Clinical Guideline (1)

•Journal Article (238)

•Legislation/Regulation (7)

•Meeting/Conference (5)

•Newspaper/Magazine Article (37)

•Press Release/Announcement (7)

•Special or Theme Issue (14)

•Tools/Toolkit (3)

•Web Resource (6)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (55)

•Active Errors (45)

•Latent Errors (32)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (191)

•Legal and Policy Approaches (31)

•Error Reporting and Analysis (123)

•Communication Improvement (33)

•Human Factors Engineering (148)

•Teamwork (26)

•Specialization of Care (6)

•Logistical Approaches (13)

•Culture of Safety (48)

•Technologic Approaches (57)

•Education and Training (45)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (160)

•Health Care Executives and Administrators (308)

•Non-Health Care Professionals (260)

•Patients (15)

Setting of Care

•Hospitals (161)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (20)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 353

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NEWSPAPER/MAGAZINE ARTICLE

Pharmaceutical industry and medical device companies: part of the solution?

ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.

PRESS RELEASE/ANNOUNCEMENT

United States marshals seize defective infusion pumps made by Alaris Products.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.

COMMENTARY

MRI suites: safety outside the bore.

Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.

AUDIOVISUAL

Safety Information on Alaris SE Infusion Pumps.

Food and Drug Administration (FDA) Patient Safety News. Show #57. November 2006.

STUDY

Usability study of two common defibrillators reveals hazards.

Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Ann Emerg Med. 2007;50:424-432.

PRESS RELEASE/ANNOUNCEMENT

Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.

Rockville, MD: US Food and Drug Administration; November 9, 2010.

STUDY

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.

STUDY

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.

Valentin A, Capuzzo M, Guidet B, et al. Intensive Care Med. 2006;32:1591-1598.

NEWSPAPER/MAGAZINE ARTICLE

Pump design flaws demonstrate need for practitioner involvement in FMEA.

ISMP Medication Safety Alert! Acute Care Edition. May 4, 2006:11:1-2,4.

COMMENTARY

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.

STUDY

Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward.

van Tilburg CM, Leistikow IP, Rademaker CM, Bierings MB, van Dijk AT. Qual Saf Health Care. 2006;15:58-63.

STUDY

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv. 2002;28:248-267, 209.

SPECIAL OR THEME ISSUE

Safety by design.

Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing adverse events caused by emergency electrical power system failures.

Sentinel Event Alert. September 6, 2006;(37):1-3.

MULTI-USE WEBSITE

Tubing and Luer Misconnections: Preventing Dangerous Medical Errors.

US Food and Drug Administration.

BOOK/REPORT

Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

Center for Devices and Radiological Health. Bethesda, MD: Food and Drug Administration, US Dept of Health and Human Services; 2006.

STUDY

'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England.

Bion J, Richardson A, Hibbert P; Matching Michigan Collaboration & Writing Committee. BMJ Qual Saf. 2013;22:110-123.

REVIEW

Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.

Johnson JR, Kuskowski MA, Wilt TJ. Ann Intern Med. 2006;144:116-126.

STUDY

Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.

Armbruster DA, Alexander DB. Clin Chim Acta. 2006;373:37-43.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

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