AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (148)

•Diagnostic Errors (200)

•Identification Errors (104)

•Discontinuities, Gaps, and Hand-Off Problems (483)

•Fatigue and Sleep Deprivation (92)

•Medication Safety (1116)

•Medical Complications (457)

•Nonsurgical Procedural Complications (94)

•Surgical Complications (394)

•Transfusion Complications (15)

•Psychological and Social Complications (161)

Origin/Sponsor

•Australia and New Zealand (100)

•Central and South America (5)

•Europe (396)

•North America (3131)

Resource Types

•Audiovisual (38)

•Bibliography (3)

•Book/Report (238)

•Clinical Guideline (9)

•Journal Article (2668)

•Legislation/Regulation (63)

•Meeting/Conference (37)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (342)

•Press Release/Announcement (31)

•Special or Theme Issue (66)

•Tools/Toolkit (71)

•Web Resource (127)

Error Types

•Epidemiology of Errors and Adverse Events (761)

•Active Errors (579)

•Latent Errors (261)

•Near Miss (66)

Approach to Improving Safety

•Quality Improvement Strategies (917)

•Legal and Policy Approaches (364)

•Error Reporting and Analysis (956)

•Communication Improvement (1199)

•Human Factors Engineering (465)

•Teamwork (401)

•Specialization of Care (288)

•Logistical Approaches (281)

•Culture of Safety (510)

•Technologic Approaches (638)

•Education and Training (788)

Clinical Areas

•Allied Health Services (14)

•Dentistry (2)

•Medicine (2431)

•Nursing (323)

•Pharmacy (449)

Target Audience
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Health Care Providers

•Allied Health Professionals (10)

•Clinical Technologists (26)

•Physicians (546)

•Nurses (410)

•Pharmacists (213)

Setting of Care

•Hospitals (2319)

•Psychiatric Facilities (18)

•Residential Facilities (66)

•Ambulatory Care (423)

•Outpatient Surgery (42)

•Patient Transport (32)

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COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

STUDY

classic

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

Learning accountability for patient outcomes.

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

STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

Hospitalized patients' understanding of their plan of care.

O'Leary KJ, Kulkarni N, Landler MP, et al. Mayo Clin Proc. 2010;85:47-52.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

BOOK/REPORT

Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care.

Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Peer support: healthcare professionals supporting each other after adverse medical events.

van Pelt F. Qual Saf Health Care. 2008;17:249-252.

REVIEW

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

O'Leary KJ, Sehgal NL, Terrell G, Williams MV; High Performance Teams and the Hospital of the Future Project Team. J Hosp Med. 2011 Oct 31; [Epub ahead of print].

STUDY

A review of verbal order policies in acute care hospitals.

Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals boost patients' power as advisers.

Landro L. Wall Street Journal. August 8, 2007:D1.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

STUDY

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

Mohta N, Vaishnava P, Liang C, et al. BMJ Qual Saf. 2012;21:885-890.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

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