AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (204)

•Diagnostic Errors (133)

•Identification Errors (111)

•Discontinuities, Gaps, and Hand-Off Problems (457)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (990)

•Medical Complications (543)

•Nonsurgical Procedural Complications (104)

•Surgical Complications (501)

•Transfusion Complications (20)

•Psychological and Social Complications (120)

Origin/Sponsor

•Africa (4)

•Asia (45)

•Australia and New Zealand (95)

•Central and South America (7)

•Europe (380)

•North America (2861)

Resource Types

•Audiovisual (37)

•Award (21)

•Book/Report (155)

•Clinical Guideline (7)

•Journal Article (2553)

•Legislation/Regulation (47)

•Meeting/Conference (11)

•Newspaper/Magazine Article (471)

•Press Release/Announcement (13)

•Special or Theme Issue (38)

•Tools/Toolkit (42)

•Web Resource (64)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (872)

•Active Errors (628)

•Latent Errors (264)

•Near Miss (61)

Approach to Improving Safety

•Quality Improvement Strategies (930)

•Legal and Policy Approaches (334)

•Error Reporting and Analysis (943)

•Communication Improvement (846)

•Human Factors Engineering (505)

•Teamwork (299)

•Specialization of Care (310)

•Logistical Approaches (299)

•Culture of Safety (475)

•Technologic Approaches (602)

•Education and Training (687)

Clinical Areas

•Allied Health Services (4)

•Medicine (2636)

•Nursing (351)

•Pharmacy (359)

Target Audience

•Health Care Providers (2431)

•Health Care Executives and Administrators (2752)

•Non-Health Care Professionals (1184)

•Patients (330)

Setting of Care
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Hospitals

•General Hospitals (1165)

•Children’s Hospitals (118)

•Specialty Hospitals (67)

1 - 20 of 3463

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COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

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

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.

AWARD RECIPIENT

Achievements in eliminating healthcare-associated infections awards.

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

ORGANIZATIONAL POLICY/GUIDELINES

Medical device alarm safety in hospitals.

Sentinel Event Alert. April 8, 2013;(50):1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative.

Pinto A, Burnett S, Benn J, et al. J Eval Clin Pract. 2011;17:180-187.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

COMMENTARY

Infection preventionist checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Cosgrove SE, Ristaino P, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:571-575.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

COMMENTARY

Health Care–Acquired Urinary Tract Infection: The Problem and Solutions

Nicolle LE. AHRQ WebM&M [serial online]. November 2008.

COMMENTARY

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

COMMENTARY

Emerging infections: the contact precautions controversy.

Zastrow RL. Am J Nurs. 2011;111:47-53.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

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.

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.

PRESS RELEASE/ANNOUNCEMENT

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

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

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

STUDY

Infection control hazards and near misses reported by nursing students.

Geller NF, Bakken S, Currie LM, Schnall R, Larson EL. Am J Infect Control. 2010;38:811-816.

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