AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (131)

•Diagnostic Errors (143)

•Identification Errors (86)

•Discontinuities, Gaps, and Hand-Off Problems (274)

•Fatigue and Sleep Deprivation (40)

•Medication Safety (579)

•Medical Complications (230)

•Nonsurgical Procedural Complications (70)

•Surgical Complications (225)

•Transfusion Complications (19)

•Psychological and Social Complications (74)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (5)

•Central and South America (3)

•Europe (33)

•North America (2083)

Resource Types

•Clinical Guideline (6)

•Journal Article (1446)

•Legislation/Regulation (38)

•Meeting/Conference (21)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (239)

•Press Release/Announcement (16)

•Special or Theme Issue (39)

•Tools/Toolkit (38)

•Web Resource (72)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (439)

•Active Errors (343)

•Latent Errors (125)

•Near Miss (39)

Approach to Improving Safety

•Quality Improvement Strategies (528)

•Legal and Policy Approaches (211)

•Error Reporting and Analysis (544)

•Communication Improvement (566)

•Human Factors Engineering (326)

•Teamwork (163)

•Specialization of Care (135)

•Logistical Approaches (180)

•Culture of Safety (268)

•Technologic Approaches (367)

•Education and Training (391)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (2059)

•Health Care Executives and Administrators (1597)

•Non-Health Care Professionals (759)

•Patients (203)

Setting of Care

•Hospitals (1157)

•Psychiatric Facilities (10)

•Residential Facilities (41)

•Ambulatory Care (235)

•Outpatient Surgery (25)

•Patient Transport (21)

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REVIEW

Patient safety and error reduction in surgical pathology.

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

NEWSPAPER/MAGAZINE ARTICLE

Hospitals move to cut dangerous lab errors.

Landro L. Wall Street Journal (Eastern edition). June 14, 2006:D1. [Reprinted on Post-gazette.com].

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.

NEWSLETTER/JOURNAL

Laboratory Errors & Patient Safety.

Seattle, WA: Medical Training Solutions.

COMMENTARY

Beyond the prescription: medication monitoring and adverse drug events in older adults.

Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc. 2011;59:1513-1520.

REVIEW

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-636.

STUDY

Clinical impact associated with corrected results in clinical microbiology testing.

Yuan S, Astion ML, Schapiro J, Limaye AP. J Clin Microbiol. 2005;43:2188-2193.

STUDY

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

Hayden RT, Patterson DJ, Jay DW, et al. J Pediatr. 2008;152:219-224.

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

REVIEW

Identifying cross contaminants and specimen mix-ups in surgical pathology.

Hunt JL. Adv Anat Pathol. 2008;15:211-217.

COMMENTARY

Putting power into patient safety: interventions.

Astion M. Laboratory Errors & Patient Safety. May-June 2005;1:5-8.

COMMENTARY

Responding to large-scale testing errors.

Valenstein PN, Alpern GA, Keren DF. Am J Clin Pathol. 2010;133:440-446.

STUDY

The effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique to address Joint Commission patient safety goals in specialty laboratories.

Raff LJ, Engel G, Beck KR, O'Brien AS, Bauer ME. Arch Pathol Lab Med. 2009;133:295-297.

MEETING/CONFERENCE PROCEEDINGS

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

STUDY

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

Goodyear N, Ulness BK, Prentice JL, Cookson BT, Limaye AP. Arch Pathol Lab Med. 2008;132:1792-1795.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

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.

STUDY

Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods.

Raab SS, Andrew-Jaja C, Condel JL, Dabbs DJ. Am J Obstet Gynecol. 2006;194:57-64.

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