AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (138)

•Identification Errors (27)

•Discontinuities, Gaps, and Hand-Off Problems (116)

•Fatigue and Sleep Deprivation (59)

•Medication Safety (250)

•Medical Complications (40)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (154)

•Transfusion Complications (1)

•Psychological and Social Complications (52)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (6)

•Journal Article (748)

•Legislation/Regulation (18)

•Meeting/Conference (3)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (133)

•Press Release/Announcement (4)

•Special or Theme Issue (10)

•Tools/Toolkit (13)

•Web Resource (18)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (193)

•Active Errors (145)

•Latent Errors (40)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (213)

•Legal and Policy Approaches (94)

•Error Reporting and Analysis (276)

•Communication Improvement (220)

•Human Factors Engineering (73)

•Teamwork (59)

•Specialization of Care (46)

•Logistical Approaches (99)

•Culture of Safety (80)

•Technologic Approaches (157)

•Education and Training (213)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (974)

•Health Care Executives and Administrators (569)

•Non-Health Care Professionals (290)

•Patients (81)

Setting of Care

•Hospitals (478)

•Residential Facilities (6)

•Ambulatory Care (93)

•Outpatient Surgery (13)

•Patient Transport (2)

1 - 20 of 989

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STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

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

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

REVIEW

The neurologist and patient safety.

Glick TH. Neurologist. 2005;11:140-149.

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.

COMMENTARY

NFL concussions and common sense: a recipe for medical errors and a lesson for physician leaders.

Lazarus A. Physician Exec. Jan-Feb 2011;37:6-9.

STUDY

When the bone flap hits the floor.

Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.

COMMENTARY

"Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist?

Benbadis SR. Neurology. 2013;80(suppl 1):S47-S51.

NEWSPAPER/MAGAZINE ARTICLE

Why doctors so often get it wrong.

Leonhardt D. New York Times. February 22, 2006;Business section:1.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

NEWSPAPER/MAGAZINE ARTICLE

Difficulty identifying Alzheimer's makes misdiagnosis easy.

Ackerman T. Houston Chronicle. November 23, 2012.

STUDY

The prevalence of wrong level surgery among spine surgeons.

Mody MG, Nourbakhsh A, Stahl DL, Gibbs M, Alfawareh M, Garges KJ. Spine. 2008;33:194-198.

BOOK/REPORT

Why Current Breast Pathology Practices Must Be Evaluated.

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

STUDY

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

Smith ER, Butler WE, Barker FG 2nd. J Neurosurg. 2006;105(suppl 3):169-176.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

REVIEW

Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice.

McConnell DJ, Fargen KM, Mocco J. Surg Neurol Int. 2012;3:2.

STUDY

Bedside detection of awareness in the vegetative state: a cohort study.

Cruse D, Chennu S, Chatelle C, et al. Lancet. 2012;378:2088-2094.

NEWSPAPER/MAGAZINE ARTICLE

For second opinion, consult a computer?

Hafner K. New York Times. December 3, 2012.

NEWSPAPER/MAGAZINE ARTICLE

Thinking about our thinking as physicians.

Groopman J, Hartzband P. ACP Internist. October 2011.

STUDY

Examining the diagnostic justification abilities of fourth-year medical students.

Williams RG, Klamen DL. Acad Med. 2012;87:1008-1014.

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