AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (104)

•Diagnostic Errors (135)

•Identification Errors (75)

•Discontinuities, Gaps, and Hand-Off Problems (514)

•Fatigue and Sleep Deprivation (59)

•Medication Safety (722)

•Medical Complications (299)

•Nonsurgical Procedural Complications (66)

•Surgical Complications (269)

•Transfusion Complications (13)

•Psychological and Social Complications (71)

Origin/Sponsor

•Africa (3)

•Asia (34)

•Australia and New Zealand (87)

•Central and South America (5)

•Europe (357)

•North America (1712)

Resource Types

•Audiovisual (9)

•Award (8)

•Book/Report (105)

•Clinical Guideline (4)

•Journal Article (1806)

•Legislation/Regulation (30)

•Meeting/Conference (14)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (141)

•Press Release/Announcement (12)

•Special or Theme Issue (30)

•Tools/Toolkit (30)

•Web Resource (48)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (614)

•Active Errors (462)

•Latent Errors (172)

•Near Miss (45)

Approach to Improving Safety

•Quality Improvement Strategies (549)

•Legal and Policy Approaches (131)

•Error Reporting and Analysis (491)

•Communication Improvement (755)

•Human Factors Engineering (324)

•Teamwork (216)

•Specialization of Care (191)

•Logistical Approaches (177)

•Culture of Safety (256)

•Technologic Approaches (542)

•Education and Training (443)

Clinical Areas

•Allied Health Services (8)

Target Audience
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Health Care Providers

•Allied Health Professionals (1)

•Clinical Technologists (7)

Setting of Care

•Psychiatric Facilities (10)

•Residential Facilities (39)

•Ambulatory Care (274)

•Outpatient Surgery (20)

•Patient Transport (23)

1 - 20 of 2245

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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

Multi-professional patterns and methods of communication during patient handoffs.

Benham-Hutchins MM, Effken JA. Int J Med Inform. 2010;79:252-267.

COMMENTARY

Time to sign off on signout.

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

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

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

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. J Hosp Med. 2011;6:329-337.

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

Electronic health records and adverse drug events after patient transfer.

Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.

STUDY

Medicines reconciliation using a shared electronic health care record.

Moore P, Armitage G, Wright J, Dobrzanski S, Ansari N, Hammond I, Scally A. J Patient Saf. 2011;7:147-153.

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

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

STUDY

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

REVIEW

Hospitalist handoffs: a systematic review and task force recommendations.

Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

REVIEW

Review of computerized physician handoff tools for improving the quality of patient care.

Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2012 Nov 20; [Epub ahead of print].

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

STUDY

Effect of admission medication reconciliation on adverse drug events from admission medication changes.

Boockvar KS, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-861.

STUDY

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

Apker J, Mallak LA, Applegate EB 3rd, et al. Ann Emerg Med. 2010;55:161-170.

STUDY

Developing a programme for medication reconciliation at the time of admission into hospital.

Manzorro AG, Zoni AC, Rieiro CR, et al. Int J Clin Pharm. 2011;33:603-609.

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