AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (78)

•Diagnostic Errors (84)

•Identification Errors (57)

•Discontinuities, Gaps, and Hand-Off Problems (224)

•Fatigue and Sleep Deprivation (46)

•Medication Safety (566)

•Medical Complications (235)

•Nonsurgical Procedural Complications (60)

•Surgical Complications (231)

•Transfusion Complications (9)

•Psychological and Social Complications (75)

Origin/Sponsor

•Africa (3)

•Asia (3)

•Australia and New Zealand (10)

•Central and South America (2)

•Europe (49)

•North America (2028)

Resource Types

•Clinical Guideline (5)

•Journal Article (1350)

•Legislation/Regulation (46)

•Meeting/Conference (29)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (232)

•Press Release/Announcement (13)

•Special or Theme Issue (37)

•Tools/Toolkit (41)

•Web Resource (87)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (409)

•Active Errors (299)

•Latent Errors (106)

•Near Miss (38)

Approach to Improving Safety

•Quality Improvement Strategies (518)

•Legal and Policy Approaches (312)

•Error Reporting and Analysis (548)

•Communication Improvement (556)

•Human Factors Engineering (258)

•Teamwork (172)

•Specialization of Care (132)

•Logistical Approaches (129)

•Culture of Safety (282)

•Technologic Approaches (329)

•Education and Training (393)

Clinical Areas

•Allied Health Services (6)

Target Audience
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Health Care Providers

•Allied Health Professionals (2)

•Clinical Technologists (3)

Setting of Care

•Psychiatric Facilities (12)

•Residential Facilities (43)

•Ambulatory Care (234)

•Outpatient Surgery (29)

•Patient Transport (18)

1 - 20 of 2085

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NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

BOOK/REPORT

A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.

Stremikis K, Schoen C, Fryer AK. 2011;6:1492.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.

COMMENTARY

Setting priorities for patient safety: ethics, accountability, and public engagement.

Pronovost PJ, Faden RR. JAMA. 2009;302:890-891.

STUDY

Beyond negligence: avoidability and medical injury compensation.

Kachalia AB, Mello MM, Brennan TA, Studdert DM. Soc Sci Med. 2008;66:387-402.

COMMENTARY

Building accountability through patient safety organizations.

Ross J. J Perianesth Nurs. 2007;22:346-348.

ORGANIZATIONAL POLICY/GUIDELINES

Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.

Goodman KW, Berner ES, Dente MA, et al; AMIA Board of Directors. J Am Med Inform Assoc. 2011;18:77-81.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #520: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2012;119:686-689.

REVIEW

Disclosing harmful medical errors to patients.

Gallagher TH, Studdert D, Levinson W. N Engl J Med. 2007;356:2713-2719.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

COMMENTARY

The Perruche case and the issue of compensation for the consequences of medical error.

Costich JF. Health Policy. 2006;78:8-16.

COMMENTARY

The partnership with patients: a call to action for leaders.

Denham CR. J Patient Saf. 2011;7:113-121.

STUDY

How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?

White RH, Sadeghi B, Tancredi DJ, et al. Med Care. 2009;47:1237-1243.

NEWSPAPER/MAGAZINE ARTICLE

In a crisis, do-not-revive requests don't always work.

Parker L. USA Today. December 19, 2006.

COMMENTARY

Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.

Bovbjerg RR, Tancredi LR. J Law Med Ethics. 2005;33:478-500.

NEWSPAPER/MAGAZINE ARTICLE

Doctors fear criminalization of medical mistakes.

Sorrel AL. American Medical News. November 27, 2006.

COMMENTARY

Ending extra payment for "never events"—stronger incentives for patients' safety.

Milstein A. N Engl J Med. 2009;360:2388-2390.

COMMENTARY classic

The wisdom and justice of not paying for "preventable complications."

Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.

REVIEW

Narrative review: do state laws make it easier to say "I'm sorry?"

McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

AUDIOVISUAL classic

"To Err Is Human" Report Retrospective and the Decade Ahead.

2009 NPSF Congress: Lucian Leape Institute Plenary. Boston, MA: National Patient Safety Foundation; May 21, 2009.

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