AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (113)

•Diagnostic Errors (45)

•Identification Errors (64)

•Discontinuities, Gaps, and Hand-Off Problems (184)

•Fatigue and Sleep Deprivation (38)

•Medication Safety (392)

•Medical Complications (362)

•Nonsurgical Procedural Complications (86)

•Surgical Complications (405)

•Transfusion Complications (10)

•Psychological and Social Complications (50)

Origin/Sponsor

•Africa (1)

•Asia (25)

•Australia and New Zealand (49)

•Central and South America (1)

•Europe (451)

•North America (1123)

Resource Types

•Audiovisual (14)

•Award (3)

•Book/Report (97)

•Clinical Guideline (3)

•Journal Article (1322)

•Legislation/Regulation (21)

•Meeting/Conference (1)

•Newspaper/Magazine Article (135)

•Press Release/Announcement (8)

•Special or Theme Issue (22)

•Tools/Toolkit (22)

•Web Resource (30)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (456)

•Active Errors (261)

•Latent Errors (127)

•Near Miss (33)

Approach to Improving Safety

•Quality Improvement Strategies (479)

•Legal and Policy Approaches (126)

•Error Reporting and Analysis (560)

•Communication Improvement (380)

•Human Factors Engineering (281)

•Teamwork (183)

•Specialization of Care (109)

•Logistical Approaches (114)

•Culture of Safety (236)

•Technologic Approaches (228)

•Education and Training (315)

Clinical Areas

•Allied Health Services (4)

•Medicine (1357)

•Nursing (170)

•Pharmacy (129)

Target Audience

•Health Care Providers (1083)

•Health Care Executives and Administrators (1509)

•Non-Health Care Professionals (631)

•Patients (98)

Setting of Care
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Hospitals

•General Hospitals (561)

•Children’s Hospitals (16)

•Specialty Hospitals (8)

1 - 20 of 1680

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SPECIAL OR THEME ISSUE

Validity of Patient Safety Indicators in the Veterans Health Administration.

J Am Coll Surg. 2011;212:921-990.

STUDY

Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.

Raleigh VS, Cooper J, Bremner SA, Scobie S. BMJ. 2008;337:a1702.

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

STUDY

How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.

Hauck K, Zhao X. Med Care. 2011;49:1068-1075.

COMMENTARY

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.

Pryor D, Hendrich A, Henkel RJ, Beckmann JK, Tersigni AR. Health Aff (Millwood). 2011;30:604-611.

STUDY

Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.

Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.

FACT SHEET/FAQS classic

10 Patient Safety Tips for Hospitals.

Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

BOOK/REPORT

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

STUDY

Developing a patient measure of safety (PMOS).

Giles SJ, Lawton RJ, Din I, McEachan RR. BMJ Qual Saf. 2013 Feb 27; [Epub ahead of print].

AWARD RECIPIENT

Achievements in eliminating healthcare-associated infections awards.

Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

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

COMMENTARY

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

STUDY

Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007.

Burton DC, Edwards JR, Horan TC, Jernigan JA, Fridkin SK. JAMA. 2009;301:727-736.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

COMMENTARY

Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators.

Utter GH, Borzecki AM, Rosen AK, et al. Jt Comm J Qual Patient Saf. 2011;37:20-28.

STUDY

A systematic quantitative assessment of risks associated with poor communication in surgical care.

Nagpal K, Vats A, Ahmed K, et al. Arch Surg. 2010;145:582-588.

PRESS RELEASE/ANNOUNCEMENT

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

Oakbrook Terrace, IL: Joint Commission; May 17, 2011.

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