AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (116)

•Diagnostic Errors (156)

•Identification Errors (83)

•Discontinuities, Gaps, and Hand-Off Problems (559)

•Fatigue and Sleep Deprivation (75)

•Medication Safety (946)

•Medical Complications (332)

•Nonsurgical Procedural Complications (75)

•Surgical Complications (309)

•Transfusion Complications (11)

•Psychological and Social Complications (137)

Origin/Sponsor

•Africa (2)

•Asia (16)

•Australia and New Zealand (64)

•Central and South America (2)

•Europe (262)

•North America (2686)

Resource Types

•Clinical Guideline (6)

•Journal Article (2243)

•Legislation/Regulation (42)

•Meeting/Conference (30)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (279)

•Press Release/Announcement (13)

•Special or Theme Issue (52)

•Tools/Toolkit (53)

•Web Resource (88)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (658)

•Active Errors (498)

•Latent Errors (198)

•Near Miss (54)

Approach to Improving Safety

•Quality Improvement Strategies (716)

•Legal and Policy Approaches (278)

•Error Reporting and Analysis (732)

•Communication Improvement (957)

•Human Factors Engineering (389)

•Teamwork (278)

•Specialization of Care (216)

•Logistical Approaches (226)

•Culture of Safety (402)

•Technologic Approaches (660)

•Education and Training (581)

Clinical Areas

•Allied Health Services (10)

Target Audience
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Health Care Providers

•Allied Health Professionals (5)

•Clinical Technologists (18)

Setting of Care

•Psychiatric Facilities (14)

•Residential Facilities (55)

•Ambulatory Care (373)

•Outpatient Surgery (30)

•Patient Transport (28)

1 - 20 of 3077

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STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.

Zsenits B, Polashenski WA, Sterns RH, Brown DR IV, Moheet A. J Hosp Med. 2009;4:308-312.

STUDY

The Veterans Affairs shift change physician-to-physician handoff project.

Anderson J, Shroff D, Curtis A, et al. Jt Comm J Qual Patient Saf. 2010;36:62-71.

STUDY

Detecting unapproved abbreviations in the electronic medical record.

Capraro A, Stack A, Harper MB, Kimia A. Jt Comm J Qual Patient Saf. 2012;38:178-183.

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

STUDY

What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Qual Saf Health Care. 2009;18:248-255.

STUDY

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2013;39:213-220.

STUDY

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.

Dalal AK, Poon EG, Karson AS, Gandhi TK, Roy CL. J Hosp Med. 2011;6:16-21.

STUDY

Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations.

Sehgal NL, Green A, Vidyarthi AR, Blegen MA, Wachter RM. J Hosp Med. 2010;5:234-239.

STUDY

Standardizing hospital discharge planning at the Mayo Clinic.

Holland DE, Hemann MA. Jt Comm J Qual Patient Saf. 2011;37:29-36.

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

Medication reconciliation in a community, nonteaching hospital.

Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.

STUDY

Discrepancies between home medications listed at hospital admission and reported medical conditions.

Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.

REVIEW

Improving patient handovers from hospital to primary care: a systematic review.

Hesselink G, Schoonhoven L, Barach P, et al. Ann Intern Med. 2012;157:417-428.

COMMENTARY

Application of electronic health records to The Joint Commission's 2011 National Patient Safety Goals.

Radecki RP, Sittig DF. JAMA. 2011;306:92-93.

COMMENTARY

A leadership initiative to improve communication and enhance safety.

Donahue M, Miller M, Smith L, Dykes P, Fitzpatrick JJ. Am J Med Qual. 2011;26:206-211.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

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