AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (18)

•Identification Errors (18)

•Discontinuities, Gaps, and Hand-Off Problems (51)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (190)

•Medical Complications (27)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (9)

•Transfusion Complications (4)

•Psychological and Social Complications (12)

Origin/Sponsor

•Asia (15)

•Australia and New Zealand (18)

Resource Types

•Journal Article (306)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newspaper/Magazine Article (78)

•Press Release/Announcement (3)

•Special or Theme Issue (5)

•Tools/Toolkit (6)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (103)

•Active Errors (65)

•Latent Errors (50)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (86)

•Legal and Policy Approaches (36)

•Error Reporting and Analysis (167)

•Communication Improvement (80)

•Human Factors Engineering (51)

•Teamwork (13)

•Specialization of Care (27)

•Logistical Approaches (28)

•Culture of Safety (43)

•Technologic Approaches (233)

•Education and Training (64)

Clinical Areas

•Medicine (313)

•Nursing (38)

•Pharmacy (84)

Target Audience

•Health Care Providers (255)

•Health Care Executives and Administrators (339)

•Non-Health Care Professionals (283)

•Patients (37)

Setting of Care
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Hospitals

•General Hospitals (23)

•Children’s Hospitals (3)

•Specialty Hospitals (1)

1 - 20 of 439

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COMMENTARY

Glucose Roller Coaster.

Sharpe BA. AHRQ WebM&M [serial online]. July 2004.

STUDY

Results of a survey on medical error reporting systems in Korean hospitals.

Kim J, Bates DW. Int J Med Inform. 2006;75:148-155.

STUDY

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting.

Anderson JE, Kodate N, Walters R, Dodds A. Int J Qual Health Care. 2013;25:141-150.

STUDY

Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference.

McVeigh TP, Waters PS, Murphy R, O'Donoghue GT, McLaughlin R, Kerin MJ. J Am Coll Surg. 2013;216:50-56.

COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

STUDY

Enhanced detection of blood bank sample collection errors with a centralized patient database.

MacIvor D, Triulzi DJ, Yazer MH. Transfusion. 2009;49:40-43.

STUDY

Decoding laboratory test names: a major challenge to appropriate patient care.

Passiment E, Meisel JL, Fontanesi J, Fritsma G, Aleryani S, Marques M. J Gen Intern Med. 2013;28:453-458.

COMMENTARY

Implementing computerized physician order management at a community hospital.

Kraus S, Barber TR, Briggs B, et al. Jt Comm J Qual Patient Saf. 2008;34:74-84.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Barriers to nurses' reporting of medication administration errors in Taiwan.

Chiang HY, Pepper GA. J Nurs Scholarsh. 2006;38:392-399.

BOOK/REPORT

Findings and Lessons From the Enabling Patient-Centered Care Through Health IT Grant Initiative.

Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0011-EF.

STUDY

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

Szekendi MK, Sullivan C, Bobb A, et al. Qual Saf Health Care. 2006;15:184-190.

COMMENTARY

A nurse-driven system for improving patient quality outcomes.

Johnson K, Hallsey D, Meredith RL, Warden E. J Nurs Care Qual. 2006;21:168-175.

AUDIOVISUAL

Avoiding medical error.

Colvin G. "The Colvin Interview." CNN. February 5, 2007.

STUDY

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

STUDY

A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.

Raschke RA, Gollihare B, Wunderlich TA, et al. [published correction appears in JAMA. 1999;281:420]. JAMA. 1998;280:1317-1320.

NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

STUDY

Evaluation of an inpatient computerized medication reconciliation system.

Turchin A, Hamann C, Schnipper JL, et al. J Am Med Inform Assoc. 2008;15:449-452.

REVIEW

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. CMAJ. 2005;173:510-515.

COMMENTARY

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.

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