AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (139)

•Diagnostic Errors (135)

•Identification Errors (92)

•Discontinuities, Gaps, and Hand-Off Problems (433)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (901)

•Medical Complications (553)

•Nonsurgical Procedural Complications (69)

•Surgical Complications (518)

•Transfusion Complications (18)

•Psychological and Social Complications (143)

Origin/Sponsor

•Africa (3)

•Asia (27)

•Australia and New Zealand (61)

•Central and South America (2)

•Europe (278)

•North America (3131)

Resource Types

•Clinical Guideline (3)

•Journal Article (2223)

•Legislation/Regulation (59)

•Meeting/Conference (14)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (620)

•Press Release/Announcement (12)

•Special or Theme Issue (41)

•Tools/Toolkit (67)

•Web Resource (105)

•Grant (15)

Error Types

•Epidemiology of Errors and Adverse Events (696)

•Active Errors (434)

•Latent Errors (232)

•Near Miss (44)

Approach to Improving Safety

•Quality Improvement Strategies (839)

•Legal and Policy Approaches (636)

•Error Reporting and Analysis (1029)

•Communication Improvement (835)

•Human Factors Engineering (385)

•Teamwork (239)

•Specialization of Care (248)

•Logistical Approaches (277)

•Culture of Safety (490)

•Technologic Approaches (588)

•Education and Training (696)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (2106)

•Health Care Executives and Administrators (2491)

•Non-Health Care Professionals (1398)

•Patients (677)

Setting of Care

•Hospitals (2774)

•Psychiatric Facilities (11)

•Residential Facilities (40)

•Ambulatory Care (302)

•Outpatient Surgery (50)

•Patient Transport (6)

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NEWSPAPER/MAGAZINE ARTICLE

Minnesota is first state with policy to stop billing after medical errors.

Lerner M. Star Tribune. September 18, 2007;News section:5B.

NEWSPAPER/MAGAZINE ARTICLE

More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.

Aleccia J. MSNBC News. August 12, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Medicare says it won't cover hospital errors.

Pear R. New York Times. August 19, 2007.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

CMS seeks to add 9 hospital-acquired conditions to no-pay list.

O'Reilly KB. American Medical News. May 12, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Insurers stop paying for care linked to errors.

Fuhrmans V. Wall Street Journal. January 15, 2008:D1.

STUDY

Medicare's policy not to pay for treating hospital-acquired conditions: the impact.

McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors leave devastating impact on families, professionals.

Bernhard B. St. Louis Post-Dispatch. May 5, 2013:A10.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals tally their avoidable mistakes.

Rein L. Washington Post. July 21, 2009:E1.

NEWSPAPER/MAGAZINE ARTICLE

'Never' land.

Carpenter D. Hosp Health Netw. November 2007;81:34-38.

COMMENTARY

Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.

Clark PA. J Law Med Ethics. 2004;32:349-357.

NEWSPAPER/MAGAZINE ARTICLE

Medicare releases patient safety ratings for hospitals.

Rau J. Kaiser Health News. October 17, 2011.

BOOK/REPORT

HealthGrades Eighth Annual Patient Safety in American Hospitals Study.

Reed K, May R. Denver, CO: HealthGrades, Inc.; March 2011.

COMMENTARY

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Kavanagh KT. Soc Work Public Health. 2011;26:524-541.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

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.

NEWSPAPER/MAGAZINE ARTICLE

Avoidable mistakes rise despite hospital efforts.

Colliver V. San Francisco Chronicle. June 2, 2010;A1.

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