AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (177)

•Diagnostic Errors (131)

•Identification Errors (108)

•Discontinuities, Gaps, and Hand-Off Problems (479)

•Fatigue and Sleep Deprivation (100)

•Medication Safety (1071)

•Medical Complications (528)

•Nonsurgical Procedural Complications (86)

•Surgical Complications (609)

•Transfusion Complications (21)

•Psychological and Social Complications (135)

Origin/Sponsor

•Africa (5)

•Asia (55)

•Australia and New Zealand (108)

•Central and South America (9)

•Europe (478)

•North America (3000)

Resource Types

•Audiovisual (41)

•Award (23)

•Book/Report (191)

•Clinical Guideline (6)

•Journal Article (2772)

•Legislation/Regulation (41)

•Meeting/Conference (11)

•Newspaper/Magazine Article (454)

•Press Release/Announcement (12)

•Special or Theme Issue (42)

•Tools/Toolkit (47)

•Web Resource (73)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (1103)

•Active Errors (558)

•Latent Errors (259)

•Near Miss (65)

Approach to Improving Safety

•Quality Improvement Strategies (919)

•Legal and Policy Approaches (361)

•Error Reporting and Analysis (1053)

•Communication Improvement (886)

•Human Factors Engineering (491)

•Teamwork (381)

•Specialization of Care (331)

•Logistical Approaches (315)

•Culture of Safety (519)

•Technologic Approaches (606)

•Education and Training (719)

Clinical Areas

•Allied Health Services (3)

•Medicine (2875)

•Nursing (344)

•Pharmacy (398)

Target Audience

•Health Care Providers (2495)

•Health Care Executives and Administrators (2873)

•Non-Health Care Professionals (1266)

•Patients (327)

Setting of Care
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Hospitals

•General Hospitals (1268)

•Children’s Hospitals (133)

•Specialty Hospitals (77)

1 - 20 of 3715

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STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Injury and death associated with incidents reported to the Patient Safety Net.

Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

COMMENTARY

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

Lubomski LH, Marsteller JA, Hsu YJ, et al. Jt Comm J Qual Patient Saf. 2008;34:619-623.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

STUDY

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting.

Makowsky MJ, Schindel TJ, Rosenthal M, Campbell K, Tsuyuki RT, Madill HM. J Interprof Care. 2009;23:169-84.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

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

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

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