AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (79)

•Diagnostic Errors (132)

•Identification Errors (49)

•Discontinuities, Gaps, and Hand-Off Problems (197)

•Fatigue and Sleep Deprivation (78)

•Medication Safety (433)

•Medical Complications (176)

•Nonsurgical Procedural Complications (76)

•Surgical Complications (501)

•Transfusion Complications (5)

•Psychological and Social Complications (80)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (11)

•Europe (81)

•North America (1649)

Resource Types

•Audiovisual (22)

•Award (3)

•Book/Report (47)

•Clinical Guideline (10)

•Journal Article (1299)

•Legislation/Regulation (40)

•Meeting/Conference (7)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (239)

•Press Release/Announcement (9)

•Special or Theme Issue (34)

•Tools/Toolkit (22)

•Web Resource (33)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (305)

•Active Errors (241)

•Latent Errors (88)

•Near Miss (22)

Approach to Improving Safety

•Quality Improvement Strategies (540)

•Legal and Policy Approaches (163)

•Error Reporting and Analysis (437)

•Communication Improvement (436)

•Human Factors Engineering (207)

•Teamwork (251)

•Specialization of Care (87)

•Logistical Approaches (144)

•Culture of Safety (193)

•Technologic Approaches (251)

•Education and Training (493)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1518)

•Health Care Executives and Administrators (1135)

•Non-Health Care Professionals (552)

•Patients (155)

Setting of Care

•Hospitals (1079)

•Psychiatric Facilities (2)

•Residential Facilities (10)

•Ambulatory Care (136)

•Outpatient Surgery (33)

•Patient Transport (4)

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COMMENTARY

In situ simulation: a method of experiential learning to promote safety and team behavior.

Miller KK, Riley W, Davis S, Hansen HE. J Perinat Neonatal Nurs. 2008;22:105-113.

COMMENTARY

System errors in intrapartum electronic fetal monitoring: a case review.

Miller LA. J Midwifery Womens Health. 2005;50:507-516.

TOOLKIT

Perinatal SBAR Tools.

Institute for Healthcare Improvement.

COMMENTARY

Improving patient safety with team coordination: challenges and strategies of implementation.

Harris KT, Treanor CM, Salisbury ML. J Obset Gynol Neonatal Nurs. 2006;35:557-566.

COMMENTARY

Enhancing Patient Safety During Hand-Offs: Standardized communication and teamwork using the 'SBAR' method.

Hohenhaus S, Powell S, Hohenhaus JT. Am J Nurs. 2006;106:72A-72B.

STUDY

Liability associated with obstetric anesthesia: a closed claims analysis.

Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB. Anesthesiology. 2009;110:131-139.

SPECIAL OR THEME ISSUE

Iatrogenic Disease.

Hermansen MC, ed. Clin Perinatal. 2008;35:1-292.

COMMENTARY

The road to zero preventable birth injuries.

Mazza F, Kitchens J, Akin M, et al. Jt Comm J Qual Patient Saf. 2008;34:201-205.

AWARD RECIPIENT

Beth Israel cited for improving obstetrics care.

Kowalczyk L. Boston Globe. March 29, 2007:4B.

STUDY

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

STUDY

Speaking up and sharing information improves trainee neonatal resuscitations.

Katakam LI, Trickey AW, Thomas EJ. J Patient Saf. 2012;8:202-209.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

Shute N. U.S. News & World Report. January 23, 2006;140:62-63.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

COMMENTARY

Interdisciplinary team training: five lessons learned.

Contratti F, Ng G, Deeb J. Am J Nurs. 2012;112:47-52.

STUDY

Impact of CRM-based team training on obstetric outcomes and clinicians' patient safety attitudes.

Pratt SD, Mann S, Salisbury M, et al. Jt Comm J Qual Patient Saf. 2007;33:720-725.

STUDY

Risks of complications by attending physicians after performing nighttime procedures.

Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.

STUDY

Effective physician–nurse communication: a patient safety essential for labor and delivery.

Lyndon A, Zlatnik MG, Wachter RM. Am J Obstet Gynecol. 2011;205:91-96.

BOOK/REPORT

Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III).

Berns SD, ed. White Plains, NY: March of Dimes; December 2010.

STUDY

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

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