AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (138)

•Diagnostic Errors (122)

•Identification Errors (95)

•Discontinuities, Gaps, and Hand-Off Problems (240)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (1194)

•Medical Complications (299)

•Nonsurgical Procedural Complications (53)

•Surgical Complications (213)

•Transfusion Complications (10)

•Psychological and Social Complications (70)

Origin/Sponsor

•Africa (1)

•Asia (13)

•Australia and New Zealand (32)

•Central and South America (7)

•Europe (121)

•North America (2145)

Resource Types

•Audiovisual (68)

•Award (13)

•Book/Report (85)

•Clinical Guideline (4)

•Journal Article (1482)

•Legislation/Regulation (20)

•Meeting/Conference (4)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (519)

•Press Release/Announcement (17)

•Special or Theme Issue (16)

•Tools/Toolkit (46)

•Web Resource (61)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (580)

•Active Errors (676)

•Latent Errors (159)

•Near Miss (45)

Approach to Improving Safety

•Quality Improvement Strategies (496)

•Legal and Policy Approaches (347)

•Error Reporting and Analysis (648)

•Communication Improvement (572)

•Human Factors Engineering (337)

•Teamwork (116)

•Specialization of Care (242)

•Logistical Approaches (158)

•Culture of Safety (213)

•Technologic Approaches (528)

•Education and Training (394)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1595)

•Health Care Executives and Administrators (1550)

•Non-Health Care Professionals (709)

•Patients (626)

Setting of Care

•Hospitals (1610)

•Psychiatric Facilities (7)

•Residential Facilities (43)

•Ambulatory Care (198)

•Outpatient Surgery (22)

•Patient Transport (16)

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AUDIOVISUAL

Nebraska Medical Center investigates staff after girl's death.

Luby R. KETV. Omaha, NE. March 31, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Dennis Quaid's Quest.

Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.

NEWSPAPER/MAGAZINE ARTICLE

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

NEWSPAPER/MAGAZINE ARTICLE

MGH faces suit over drug error that killed woman.

Valencia MJ. Boston Globe. March 10, 2011.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

AUDIOVISUAL

State launches 3rd priority investigation into Children's.

Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Heparin errors continue despite prior, high-profile, fatal events.

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2008;13:1-2.

STUDY

Medication errors resulting from computer entry by nonprescribers.

Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA. Am J Health Syst Pharm. 2009;66:843-853.

STUDY

Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients.

Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Am J Health Syst Pharm. 2008;65:1254-1260.

STUDY

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system.

Agrawal A, Wu WY. Jt Comm J Qual Patient Saf. 2009;35:106-114.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

NEWSPAPER/MAGAZINE ARTICLE

Hospital drug errors far from uncommon.

Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.

NEWSPAPER/MAGAZINE ARTICLE

Dennis Quaid files suit over drug mishap.

Ornstein C. Los Angeles Times. December 5, 2007:B1.

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.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Heparin overdose in three infants revisits hospital error issues.

Phend C. MedPage Today. November 26, 2007.

AUDIOVISUAL PRESENTATION

Mix-up: baby nursed by wrong mother.

Cisneros N. ABC-7/KGO-TV. June 10, 2006.

AUDIOVISUAL

Medical Mistakes: Dr. Oz Talks to Actor Dennis Quaid.

The Oprah Winfrey Show. March 10, 2009.

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