AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (175)

•Diagnostic Errors (198)

•Identification Errors (115)

•Discontinuities, Gaps, and Hand-Off Problems (389)

•Fatigue and Sleep Deprivation (94)

•Medication Safety (1157)

•Medical Complications (400)

•Nonsurgical Procedural Complications (132)

•Surgical Complications (475)

•Transfusion Complications (16)

•Psychological and Social Complications (110)

Origin/Sponsor

•Africa (2)

•Asia (63)

•Australia and New Zealand (101)

•Central and South America (7)

•Europe (405)

•North America (2978)

Resource Types

•Audiovisual (29)

•Award (10)

•Book/Report (120)

•Clinical Guideline (5)

•Journal Article (2991)

•Legislation/Regulation (38)

•Meeting/Conference (14)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (261)

•Press Release/Announcement (16)

•Special or Theme Issue (31)

•Tools/Toolkit (21)

•Web Resource (45)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (1447)

•Active Errors (589)

•Latent Errors (180)

•Near Miss (119)

Approach to Improving Safety

•Quality Improvement Strategies (803)

•Legal and Policy Approaches (260)

•Error Reporting and Analysis (1377)

•Communication Improvement (735)

•Human Factors Engineering (459)

•Teamwork (266)

•Specialization of Care (230)

•Logistical Approaches (269)

•Culture of Safety (405)

•Technologic Approaches (606)

•Education and Training (610)

Clinical Areas

•Allied Health Services (15)

Target Audience

•Health Care Providers (2454)

•Health Care Executives and Administrators (3095)

•Non-Health Care Professionals (1225)

•Patients (166)

Setting of Care

•Hospitals (2377)

•Psychiatric Facilities (13)

•Residential Facilities (60)

•Ambulatory Care (297)

•Outpatient Surgery (42)

•Patient Transport (30)

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STUDY

Computer based medication error reporting: insights and implications.

Miller MR, Clark JS, Lehmann CU. Qual Saf Health Care. 2006;15:208-213.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Pediatrics. 2005;116:603-608.

STUDY

Decreasing errors in pediatric continuous intravenous infusions.

Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Pediatr Crit Care Med. 2006;7:225-230.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

STUDY

Patient risk factors for medical injury: a case–control study.

Marbella AM, Laud PW, Brasel KJ, Layde PM. BMJ Qual Saf. 2011;20:187-193.

STUDY

Patient-reported safety and quality of care in outpatient oncology.

Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.

STUDY

The effect of a rapid response team on major clinical outcome measures in a community hospital.

Dacey MJ, Mirza ER, Wilcox V, et al. Crit Care Med. 2007;35:2076-2082.

STUDY

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

Woods DM, Thomas EJ, Holl JL, Weiss KB, Brennan TA. Qual Saf Health Care. 2007;16:127-131.

STUDY

Preventable harm occurring to critically ill children.

Larsen GY, Donaldson AE, Parker HB, Grant MJ. Pediatr Crit Care Med. 2007;8:331-336.

STUDY

Automated medication error studies with audit supplementation were effectively designed and analyzed by time series.

Shuster JJ, Winterstein AG. J Clin Epidemiol. 2006;59:957-963.

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.

STUDY

Antiretroviral medication errors among hospitalized patients with HIV infection.

Rastegar DA, Knight AM, Monolakis JS. Clin Infect Dis. 2006;43:933-38.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

STUDY

Analysis and prioritization of near-miss adverse events in a radiology department.

Thornton RH, Miransky J, Killen AR, Solomon SB, Brody LA. AJR Am J Roentgenol. 2011;196:1120-1124.

STUDY

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

Taylor JA, Brownstein D, Klein EJ, Strandjord TP. J Hosp Med. 2007;2:226-33.

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.

STUDY

Rate of occult specimen provenance complications in routine clinical practice.

Pfeifer JD, Liu J. Am J Clin Pathol. 2013;139:93-100.

STUDY

Outcomes after out-of-hospital endotracheal intubation errors.

Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR. Resuscitation. 2009;80:50-55.

STUDY

Underdiagnosis of hypertension in children and adolescents.

Hansen ML, Gunn PW, Kaelber DC. JAMA. 2007;298:874-879.

STUDY

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.

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