AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (54)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (507)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (225)

•Medical Complications (54)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (36)

•Transfusion Complications (1)

•Psychological and Social Complications (20)

Origin/Sponsor

•Australia and New Zealand (9)

•North America (730)

Resource Types

•Audiovisual (3)

•Book/Report (29)

•Journal Article (580)

•Legislation/Regulation (11)

•Meeting/Conference (3)

•Newspaper/Magazine Article (94)

•Press Release/Announcement (1)

•Special or Theme Issue (10)

•Tools/Toolkit (13)

•Web Resource (15)

Error Types

•Epidemiology of Errors and Adverse Events (182)

•Active Errors (100)

•Latent Errors (50)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (139)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (111)

•Communication Improvement (446)

•Human Factors Engineering (59)

•Teamwork (66)

•Specialization of Care (72)

•Logistical Approaches (89)

•Culture of Safety (39)

•Technologic Approaches (102)

•Education and Training (189)

Clinical Areas

•Allied Health Services (2)

•Medicine (592)

•Nursing (65)

•Pharmacy (82)

Target Audience

•Health Care Providers (555)

•Health Care Executives and Administrators (531)

•Non-Health Care Professionals (231)

•Patients (80)

Setting of Care

•Hospitals (577)

•Psychiatric Facilities (2)

•Residential Facilities (15)

•Ambulatory Care (98)

•Outpatient Surgery (6)

•Patient Transport (15)

1 - 20 of 761

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STUDY

Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.

Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-346.

COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

STUDY

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

Hastings SN, Barrett A, Weinberger M, et al. J Patient Saf. 2011;7:19-25.

STUDY

"Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions.

Vashi A, Rhodes KV. Ann Emerg Med. 2011;57:315-322.e1.

NEWSPAPER/MAGAZINE ARTICLE

A case that shook medicine.

Lerner BH. The Washington Post. November 28, 2006:HE01.

NEWSPAPER/MAGAZINE ARTICLE

Interruptions and distractions: workflow intrusions at a level-one trauma center.

Brixey JJ, Robinson DJ, Zhang J, Turley JP. Focus Patient Saf. 2008;11:3-4,5.

COMMENTARY

Procedural safety in emergency care: a conceptual model and recommendations.

Pines JM, Kelly JJ, Meisl H, et al. Jt Comm J Qual Patient Saf. 2012;38:516-526.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

STUDY

Teamwork errors in trauma resuscitation.

Sarcevic A, Marsic I, Burd RS. ACM Trans Comput Hum Interact. 2012;19:13:1-13:30.

ORGANIZATIONAL POLICY/GUIDELINES

Joint Policy Statement—Guidelines for Care of Children in the Emergency Department.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2009;124:1233-1243.

STUDY

Interruptions in a level one trauma center: a case study.

Brixey JJ, Tang Z, Robinson DJ, et al. Int J Med Inform. 2008;77:235-241.

STUDY

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.

Laxmisan A, Hakimzada F, Sayan OR, et al. Int J Med Inform. 2007;76:801-811.

STUDY

Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years.

Cosby KS, Roberts R, Palivos L, et al. Ann Emerg Med. 2008;51:251-61, 261.e1.

STUDY

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.

Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. Ann Emerg Med. 2009;54:381-385.

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

Eytan T. AHRQ WebM&M [serial online]. October 2008.

MULTI-USE WEBSITE

Maryland Patient Safety Center Emergency Department Collaborative.

Maryland Patient Safety Center.

COMMENTARY

Capturing more emergency department errors via an anonymous web-based reporting system.

Khare RK, Uren B, Wears RL. Qual Manag Health Care. 2005;14:91-94.

COMMENTARY

Studying the technical work of emergency care.

Nemeth CP, Cook RI, Wears RL. Ann Emerg Med. 2007;50:384-386.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety in the ED.

Scalise D, Lazar C. Hosp Health Netw. May 2006:80:5,48,2.

NEWSPAPER/MAGAZINE ARTICLE

Don't come back, hospitals say.

Landro L. Wall Street Journal. June 7, 2011:D3.

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