AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (105)

•Diagnostic Errors (97)

•Identification Errors (69)

•Discontinuities, Gaps, and Hand-Off Problems (502)

•Fatigue and Sleep Deprivation (77)

•Medication Safety (664)

•Medical Complications (375)

•Nonsurgical Procedural Complications (46)

•Surgical Complications (216)

•Transfusion Complications (16)

•Psychological and Social Complications (88)

Origin/Sponsor

•Australia and New Zealand (91)

•Central and South America (2)

•Europe (349)

•North America (1959)

Resource Types

•Audiovisual (29)

•Book/Report (173)

•Clinical Guideline (2)

•Journal Article (1787)

•Legislation/Regulation (30)

•Meeting/Conference (9)

•Newspaper/Magazine Article (323)

•Press Release/Announcement (9)

•Special or Theme Issue (29)

•Tools/Toolkit (50)

•Web Resource (69)

Error Types

•Epidemiology of Errors and Adverse Events (589)

•Active Errors (371)

•Latent Errors (225)

•Near Miss (37)

Approach to Improving Safety

•Quality Improvement Strategies (668)

•Legal and Policy Approaches (292)

•Error Reporting and Analysis (699)

•Communication Improvement (773)

•Human Factors Engineering (280)

•Teamwork (176)

•Specialization of Care (241)

•Logistical Approaches (220)

•Culture of Safety (395)

•Technologic Approaches (427)

•Education and Training (510)

Clinical Areas

•Allied Health Services (3)

•Medicine (2015)

•Nursing (148)

•Pharmacy (267)

Target Audience

•Health Care Providers (1667)

•Health Care Executives and Administrators (2013)

•Non-Health Care Professionals (928)

•Patients (254)

Setting of Care
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Hospitals

•General Hospitals (559)

•Children’s Hospitals (65)

•Specialty Hospitals (41)

1 - 20 of 2529

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STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

MULTI-USE WEBSITE

Project Red (Re-Engineered Discharge).

Boston, MA: Boston University Medical Center.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

BOOK/REPORT

Managing Patients' Medicines after Discharge from Hospital.

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

STUDY

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

Williams TA, Leslie GD, Elliott N, Brearley L, Dobb GJ. J Nurs Care Qual. 2010;25:73-79.

STUDY

classic

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

TOOLKIT

Re-Engineered Discharge (RED) Toolkit.

Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

STUDY

classic

Do medical inpatients who report poor service quality experience more adverse events and medical errors?

Taylor BB, Marcantonio ER, Pagovich O, et al. Med Care. 2008;46:224-228.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

COMMENTARY

Culture, language, and patient safety: making the link.

Johnstone MJ, Kanitsaki O. Int J Qual Health Care. 2006;18:383-8.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

STUDY

Hospitalized patients' understanding of their plan of care.

O'Leary KJ, Kulkarni N, Landler MP, et al. Mayo Clin Proc. 2010;85:47-52.

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