AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (117)

•Diagnostic Errors (129)

•Identification Errors (89)

•Discontinuities, Gaps, and Hand-Off Problems (325)

•Fatigue and Sleep Deprivation (67)

•Medication Safety (817)

•Medical Complications (323)

•Nonsurgical Procedural Complications (83)

•Surgical Complications (349)

•Transfusion Complications (11)

•Psychological and Social Complications (190)

Origin/Sponsor

•Africa (5)

•Asia (25)

•Australia and New Zealand (70)

•Central and South America (3)

•Europe (232)

•North America (2592)

Resource Types

•Clinical Guideline (6)

•Journal Article (2040)

•Legislation/Regulation (51)

•Meeting/Conference (33)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (289)

•Press Release/Announcement (29)

•Special or Theme Issue (59)

•Tools/Toolkit (56)

•Web Resource (121)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (591)

•Active Errors (419)

•Latent Errors (172)

•Near Miss (56)

Approach to Improving Safety

•Quality Improvement Strategies (752)

•Legal and Policy Approaches (326)

•Error Reporting and Analysis (886)

•Communication Improvement (822)

•Human Factors Engineering (357)

•Teamwork (284)

•Specialization of Care (201)

•Logistical Approaches (196)

•Culture of Safety (448)

•Technologic Approaches (473)

•Education and Training (584)

Clinical Areas

•Allied Health Services (14)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (7)

•Clinical Technologists (18)

Setting of Care

•Psychiatric Facilities (15)

•Residential Facilities (57)

•Ambulatory Care (310)

•Outpatient Surgery (38)

•Patient Transport (31)

1 - 20 of 2988

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STUDY

Teamwork on inpatient medical units: assessing attitudes and barriers.

O'Leary KJ, Ritter CD, Wheeler H, Szekendi MK, Brinton TS, Williams MV. Qual Saf Health Care. 2010;19:117-121.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.

STUDY

Managing disruptive behaviors in the health care setting: focus on obstetrics services.

Rosenstein AH. Am J Obstet Gynecol. 2011;204:187-192.

SPECIAL OR THEME ISSUE

Medical errors and safety systems.

Pearlman MD, ed. Clin Obstet Gynecol. 2010;53:471-585.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #366: disruptive behavior.

ACOG Committee on Patient Safety and Quality Improvement of American College of Obstetricians and Gynecologists. Obstet Gynecol. 2007;109:1261-1262.

STUDY

Parents' perceptions of medical errors.

Mazor KM, Goff SL, Dodd KS, Velten SJ, Walsh KE. J Patient Saf. 2010;6:102-107.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

STUDY

An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care.

Weingart SN, Simchowitz B, Padolsky H, et al. Arch Intern Med. 2009;169;1465-1473.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.

NEWSPAPER/MAGAZINE ARTICLE

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

COMMENTARY

Disruptive clinician behavior: a persistent threat to patient safety.

Porto G, Lauve R. Patient Safety Qual Healthc. July/August 2006;3:16-24.

COMMENTARY

Errors and analysis of errors.

Mulligan MA, Nechodom P. Clin Obstet Gynecol. 2008;51:656-665.

STUDY

Perception of intimidation in a perioperative setting.

Dull DL, Fox L. Am J Med Qual. 2010;25:87-94.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #320: partnering with patients to improve safety.

ACOG Committee on Quality Improvement and Patient Safety. Obstet Gynecol. 2005;106:1123-1125.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

NEWSPAPER/MAGAZINE ARTICLE

Nurse error spotlights drug's danger.

Greene L. St. Petersburg Times. June 15, 2006:A1.

MISSOURI MEETING/CONFERENCE

The Second Victim Experience: Train-the-Trainer Workshop.

Center for Patient Safety. June 11, 2013; University of Missouri Health System Health System, Columbia, MO.

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