AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (222)

•Diagnostic Errors (211)

•Identification Errors (140)

•Discontinuities, Gaps, and Hand-Off Problems (547)

•Fatigue and Sleep Deprivation (110)

•Medication Safety (1288)

•Medical Complications (650)

•Nonsurgical Procedural Complications (123)

•Surgical Complications (550)

•Transfusion Complications (29)

•Psychological and Social Complications (170)

Origin/Sponsor

•Africa (6)

•Asia (51)

•Australia and New Zealand (120)

•Central and South America (10)

•Europe (548)

•North America (4036)

Resource Types

•Clinical Guideline (9)

•Journal Article (3509)

•Legislation/Regulation (62)

•Meeting/Conference (37)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (470)

•Press Release/Announcement (29)

•Special or Theme Issue (80)

•Tools/Toolkit (78)

•Web Resource (130)

•Grant (11)

Error Types

•Epidemiology of Errors and Adverse Events (1082)

•Active Errors (701)

•Latent Errors (295)

•Near Miss (82)

Approach to Improving Safety

•Quality Improvement Strategies (1166)

•Legal and Policy Approaches (471)

•Error Reporting and Analysis (1331)

•Communication Improvement (1143)

•Human Factors Engineering (689)

•Teamwork (491)

•Specialization of Care (345)

•Logistical Approaches (337)

•Culture of Safety (673)

•Technologic Approaches (894)

•Education and Training (971)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (3491)

•Health Care Executives and Administrators (3891)

•Non-Health Care Professionals (1819)

•Patients (375)

Setting of Care

•Hospitals (3169)

•Psychiatric Facilities (17)

•Residential Facilities (79)

•Ambulatory Care (429)

•Outpatient Surgery (48)

•Patient Transport (36)

1 - 20 of 4808

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COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

COMMENTARY classic

Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

STUDY

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

REVIEW

Hospitalist handoffs: a systematic review and task force recommendations.

Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

STUDY

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.

Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, Happ MB, Devita MA. Qual Saf Health Care. 2008;17:377-381.

COMMENTARY

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

BOOK/REPORT

Critical Care Safety: Essentials for ICU Patient Care and Technology.

Plymouth Meeting, PA: ECRI Institute; 2007. ISBN 0977914259.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: what can medicine learn from aviation?

O'Reilly KB. American Medical News. June 14, 2010.

STUDY

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

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