AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (181)

•Diagnostic Errors (301)

•Identification Errors (143)

•Discontinuities, Gaps, and Hand-Off Problems (539)

•Fatigue and Sleep Deprivation (122)

•Medication Safety (1287)

•Medical Complications (468)

•Nonsurgical Procedural Complications (94)

•Surgical Complications (521)

•Transfusion Complications (25)

•Psychological and Social Complications (275)

Origin/Sponsor

•Africa (2)

•Asia (59)

•Australia and New Zealand (102)

•Central and South America (8)

•Europe (479)

•North America (3740)

Resource Types

•Audiovisual (43)

•Award (14)

•Book/Report (182)

•Clinical Guideline (8)

•Journal Article (3491)

•Legislation/Regulation (51)

•Meeting/Conference (20)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (449)

•Press Release/Announcement (10)

•Special or Theme Issue (41)

•Tools/Toolkit (44)

•Web Resource (66)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (1476)

•Active Errors (690)

•Latent Errors (231)

•Near Miss (77)

Approach to Improving Safety

•Quality Improvement Strategies (1014)

•Legal and Policy Approaches (395)

•Error Reporting and Analysis (1437)

•Communication Improvement (1036)

•Human Factors Engineering (494)

•Teamwork (328)

•Specialization of Care (285)

•Logistical Approaches (354)

•Culture of Safety (519)

•Technologic Approaches (748)

•Education and Training (814)

Clinical Areas

•Allied Health Services (14)

Target Audience

•Health Care Providers (3108)

•Health Care Executives and Administrators (3456)

•Non-Health Care Professionals (1551)

•Patients (293)

Setting of Care

•Hospitals (2882)

•Psychiatric Facilities (15)

•Residential Facilities (60)

•Ambulatory Care (453)

•Outpatient Surgery (39)

•Patient Transport (25)

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STUDY

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. J Gen Intern Med. 2006;21:758-763.

STUDY

Types and origins of diagnostic errors in primary care settings.

Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. JAMA Intern Med. 2013;173:418-425.

STUDY

Patient perceptions of mistakes in ambulatory care.

Kistler CE, Walter LC, Mitchell CM, Sloane PD. Arch Intern Med. 2010;170:1480-1487.

REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

STUDY

Frequency of failure to inform patients of clinically significant outpatient test results.

Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

STUDY

Identifying diagnostic errors in primary care using an electronic screening algorithm.

Singh H, Thomas EJ, Khan MM, Petersen LA. Arch Intern Med. 2007;167:302-308.

STUDY

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.

López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894.

COMMENTARY

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

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

STUDY

The frequency of missed test results and associated treatment delays in a highly computerized health system.

Wahls TL, Cram PM. BMC Fam Pract. 2007;8:32.

STUDY

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

Sarkar U, Bonacum D, Strull W, et al. BMJ Qual Saf. 2012;21:641-648.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

STUDY

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

McGuire MJ, Noronha G, Samal L, Yeh HC, Crocetti S, Kravet S. J Gen Intern Med. 2013;28:184-192.

STUDY

Transitioning between electronic health records: effects on ambulatory prescribing safety.

Abramson EL, Malhotra S, Fischer K, et al. J Gen Intern Med. 2011;26:868-874.

STUDY

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. J Gen Intern Med. 2012;27:1416-1423.

STUDY

Finding blunders in thyroid testing: experience in newborns.

Zilka LJ, Lott JA, Baker LC, Linard SM. J Clin Lab Anal. 2008;22:254-256.

BOOK/REPORT

Why Current Breast Pathology Practices Must Be Evaluated.

Dallas, TX: Susan G. Komen Breast Cancer Foundation; June 2006.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

STUDY

Responding to serious medical error in general practice—consequences for the GPs involved: analysis of 75 cases from Germany.

Fisseni G, Pentzek M, Abholz H-H. Fam Pract. 2008;25:9-13.

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