AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (143)

•Diagnostic Errors (180)

•Identification Errors (116)

•Discontinuities, Gaps, and Hand-Off Problems (299)

•Fatigue and Sleep Deprivation (64)

•Medication Safety (911)

•Medical Complications (352)

•Nonsurgical Procedural Complications (93)

•Surgical Complications (409)

•Transfusion Complications (20)

•Psychological and Social Complications (94)

Origin/Sponsor

•Africa (2)

•Asia (59)

•Australia and New Zealand (118)

•Central and South America (7)

•Europe (734)

•North America (2067)

Resource Types

•Clinical Guideline (4)

•Journal Article (2269)

•Legislation/Regulation (39)

•Meeting/Conference (15)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (266)

•Press Release/Announcement (42)

•Special or Theme Issue (36)

•Tools/Toolkit (41)

•Web Resource (103)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (836)

•Active Errors (503)

•Latent Errors (192)

•Near Miss (69)

Approach to Improving Safety

•Quality Improvement Strategies (764)

•Legal and Policy Approaches (285)

•Error Reporting and Analysis (1293)

•Communication Improvement (687)

•Human Factors Engineering (413)

•Teamwork (241)

•Specialization of Care (172)

•Logistical Approaches (177)

•Culture of Safety (384)

•Technologic Approaches (465)

•Education and Training (514)

Clinical Areas

•Allied Health Services (11)

•Complementary and Alternative Medicine (2)

Target Audience

•Health Care Providers (2389)

•Health Care Executives and Administrators (2765)

•Non-Health Care Professionals (1092)

•Patients (383)

Setting of Care

•Hospitals (1771)

•Psychiatric Facilities (25)

•Residential Facilities (61)

•Ambulatory Care (292)

•Outpatient Surgery (35)

•Patient Transport (27)

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BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

Inadvertent misadministration of meningococcal conjugate vaccine—United States, June–August 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.

MULTI-USE WEBSITE

The National Report Card on the State of Emergency Medicine.

Dallas, TX: American College of Emergency Physicians.

STUDY

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.

Watkinson PJ, Barber VS, Price JD, et al. Anaesthesia. 2006;61:1031-1039.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

REVIEW

Clinical errors and medical negligence.

Oyebode F. Med Princ Pract. 2013 Jan 18; [Epub ahead of print].

STUDY

Competition and health plan performance: evidence from health maintenance organization insurance markets.

Scanlon DP, Swaminathan S, Chernew M, Bost JE, Shevock J. Med Care. 2005;43:338-346.

COMMENTARY

Drug errors, qualitative research and some reflections on ethics.

Armitage G. J Clin Nurs. 2005;14:869-875.

REVIEW

Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.

Manser T, Staender S. Acta Anaesthesiol Scand. 2005;49:728-734.

STUDY

Review of the Australian Incident Monitoring System.

Spigelman AD, Swan J. ANZ J Surg. 2005;75:657-661.

COMMENTARY

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

Hearns S, Shirley PJ. Emerg Med J. 2006;23:943-947.

TOOLKIT

Engaging Clinicians.

National Patient Safety Agency. London, England: NHS; 2005.

MEETING/CONFERENCE PROCEEDINGS

Making the Health Care System Safer Through Implementation and Innovation.

Agency for Healthcare Research and Quality. Kaisernetwork.org Web site. June 8, 2005.

TOOLKIT

Manchester Patient Safety Framework (MaPSaF).

Manchester, UK: University of Manchester; 2006.

BOOK/REPORT

Quarterly National Reporting and Learning System Data Summary.

National Patient Safety Agency. London, UK: National Health Service.

REVIEW

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

Burnett E, Kearney N, Johnston B, Corlett J, Macgillivray S. Am J Infect Control. 2013;41:394-400.

STUDY

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study.

Bowers L, Allan T, Simpson A, Nijman H, Warren J. Int J Soc Psychiatry. 2007;53:75-84.

STUDY

Adverse events and near miss reporting in the NHS.

Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.

STUDY

Towards safer neonatal transfer: the importance of critical incident review.

Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

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