AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (21)

•Medication Safety (50)

•Medical Complications (10)

•Psychological and Social Complications (3)

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•Asia (1)

•Australia and New Zealand (4)

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•North America (77)

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•Clinical Guideline (1)

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•Newspaper/Magazine Article (4)

•Special or Theme Issue (2)

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•Epidemiology of Errors and Adverse Events (33)

•Active Errors (13)

•Latent Errors (9)

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Approach to Improving Safety

•Quality Improvement Strategies (16)

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•Error Reporting and Analysis (26)

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•Human Factors Engineering (9)

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•Culture of Safety (25)

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Clinical Areas

•Allied Health Services (2)

•Medicine (85)

•Nursing (21)

•Pharmacy (11)

Target Audience

•Health Care Providers (68)

•Health Care Executives and Administrators (77)

•Non-Health Care Professionals (17)

•Patients (4)

Setting of Care
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Residential Facilities

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COMMENTARY

Workaround Error

Pape T. AHRQ WebM&M [serial online]. Febuary 2006.

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

STUDY

Safety culture of nursing homes: opinions of top managers.

Castle NG, Wagner LM, Ferguson JC, Handler SM. Health Care Manage Rev. 2011;36:175-187.

COMMENTARY

Another Fall.

Bogardus ST Jr. AHRQ WebM&M [serial online]. April 2003.

STUDY

Nurses' perceptions of safety culture in long-term care settings.

Wagner LM, Capezuti E, Rice JC. J Nurs Scholarsh. 2009;41:184-192.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

STUDY

Health outcomes associated with potentially inappropriate medication use in older adults.

Fick DM, Mion LC, Beers MH, Waller JL. Res Nurs Health. 2008;31:42-51.

STUDY

Shifting supervision: implications for safe administration of medication by nursing students.

Reid-Searl K, Moxham L, Walker S, Happell B. J Clin Nurs. 2008;17:2750-2757.

COMMENTARY

The Wrongful Resuscitation

Teno JM. AHRQ WebM&M [serial online]. April 2008.

COMMENTARY

Reporting near-miss events in nursing homes.

Wagner LM, Capezuti E, Ouslander JG. Nurs Outlook. 2006;54:85-93.

STUDY

Barriers and facilitators to communicating nursing errors in long-term care settings.

Wagner LM, Damianakis T, Pho L, Tourangeau A. J Patient Saf. 2013;9:1-7.

STUDY

Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.

Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.

STUDY

Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers?

Scott J, Dawson P, Jones D. BMJ Qual Saf. 2012;22:112-117.

PENNSYLVANIA LEGISLATION

Prohibition of Excessive Overtime for Nurses Act.

The General Assembly of Pennsylvania. HB957 (2005).

BOOK/REPORT

Focus on Patient Safety.

Fitzpatrick J, Stone P, Hinton-Walker P, eds. Annual Review of Nursing Research. New York, NY: Springer; 2006. ISBN: 0826141366.

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

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

Nursing home administrators' opinions of the resident safety culture in nursing homes.

Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

STUDY

Nurse aides' ratings of the resident safety culture in nursing homes.

Castle NG. Int J Qual Health Care. 2006;18:370-6.

STUDY

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

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