AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (162)

•Diagnostic Errors (199)

•Identification Errors (98)

•Discontinuities, Gaps, and Hand-Off Problems (355)

•Fatigue and Sleep Deprivation (61)

•Medication Safety (918)

•Medical Complications (543)

•Nonsurgical Procedural Complications (77)

•Surgical Complications (580)

•Transfusion Complications (22)

•Psychological and Social Complications (118)

Origin/Sponsor

•Africa (7)

•Asia (57)

•Australia and New Zealand (136)

•Central and South America (12)

•Europe (572)

•North America (2495)

Resource Types

•Clinical Guideline (2)

•Journal Article (2435)

•Legislation/Regulation (35)

•Meeting/Conference (32)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (243)

•Press Release/Announcement (35)

•Special or Theme Issue (68)

•Tools/Toolkit (61)

•Web Resource (115)

•Grant (18)

Error Types

•Epidemiology of Errors and Adverse Events (1240)

•Active Errors (492)

•Latent Errors (210)

•Near Miss (72)

Approach to Improving Safety

•Quality Improvement Strategies (850)

•Legal and Policy Approaches (362)

•Error Reporting and Analysis (1230)

•Communication Improvement (798)

•Human Factors Engineering (432)

•Teamwork (444)

•Specialization of Care (269)

•Logistical Approaches (217)

•Culture of Safety (508)

•Technologic Approaches (484)

•Education and Training (740)

Clinical Areas

•Allied Health Services (15)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (2692)

•Health Care Executives and Administrators (2809)

•Non-Health Care Professionals (1264)

•Patients (244)

Setting of Care

•Hospitals (2218)

•Psychiatric Facilities (17)

•Residential Facilities (63)

•Ambulatory Care (297)

•Outpatient Surgery (42)

•Patient Transport (33)

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STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

STUDY

Iatrogenic events contributing to ICU admission: a prospective study.

Mercier E, Giraudeau B, Giniès G, Perrotin D, Dequin PF. Intensive Care Med. 2010;36:1033-1037.

PRESS RELEASE/ANNOUNCEMENT classic

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes.

Kramer AA, Higgins TL, Zimmerman JE. Crit Care Med. 2012;40:3-10.

STUDY

Patient safety event reporting in critical care: a study of three intensive care units.

Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35:1068-1076.

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.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

STUDY

Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.

MERIT study investigators. Lancet. 2005;365:2091-2097.

SPECIAL OR THEME ISSUE

The safety and quality of health care: where are we now?

Med J Aust. 2006;184:S37-S72.

STUDY

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

Thompson DA, Duling L, Holzmueller CG, et al. J Clin Outcomes Manage. 2005;12:407-412.

BOOK/REPORT

Advancing Patient Safety: A Decade of Evidence, Design, and Implementation.

Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

STUDY

Multiprofessional survey of protocol use in the intensive care unit.

LeBlanc JM, Kane-Gill SL, Pohlman AS, Herr DL. J Crit Care. 2012;27:738.e9-738.e17.

BOOK/REPORT

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

Thomson R, Luettel D, Healey F, Scobie S. London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634055.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

COMMENTARY

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

COMMENTARY

Creating the web-based intensive care unit safety reporting system.

Holzmueller CG, Pronovost PJ, Dickman F, et al. J Am Med Inform Assoc. 2005;12:130-139.

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