AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (101)

•Diagnostic Errors (119)

•Identification Errors (63)

•Discontinuities, Gaps, and Hand-Off Problems (345)

•Fatigue and Sleep Deprivation (62)

•Medication Safety (666)

•Medical Complications (392)

•Nonsurgical Procedural Complications (100)

•Surgical Complications (181)

•Transfusion Complications (11)

•Psychological and Social Complications (89)

Origin/Sponsor

•Australia and New Zealand (86)

•Central and South America (5)

•Europe (330)

•North America (1828)

Resource Types

•Audiovisual (20)

•Bibliography (2)

•Book/Report (179)

•Clinical Guideline (3)

•Journal Article (1598)

•Legislation/Regulation (37)

•Meeting/Conference (24)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (208)

•Press Release/Announcement (26)

•Special or Theme Issue (51)

•Tools/Toolkit (56)

•Web Resource (93)

Error Types

•Epidemiology of Errors and Adverse Events (484)

•Active Errors (367)

•Latent Errors (202)

•Near Miss (40)

Approach to Improving Safety

•Quality Improvement Strategies (638)

•Legal and Policy Approaches (272)

•Error Reporting and Analysis (610)

•Communication Improvement (661)

•Human Factors Engineering (287)

•Teamwork (191)

•Specialization of Care (209)

•Logistical Approaches (219)

•Culture of Safety (358)

•Technologic Approaches (400)

•Education and Training (493)

Clinical Areas

•Allied Health Services (12)

•Medicine (1629)

•Nursing (150)

•Pharmacy (245)

Target Audience
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Health Care Providers

•Allied Health Professionals (4)

•Clinical Technologists (12)

•Physicians (189)

•Nurses (148)

•Pharmacists (67)

Setting of Care

•Hospitals (1662)

•Psychiatric Facilities (14)

•Residential Facilities (41)

•Ambulatory Care (256)

•Outpatient Surgery (23)

•Patient Transport (17)

1 - 20 of 2353

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MULTI-USE WEBSITE

Impact Case Studies and Knowledge Transfer Case Studies: Patient Safety.

Agency for Healthcare Research and Quality; November 2011.

STUDY

The association between night or weekend admission and hospitalization-relevant patient outcomes.

Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. J Hosp Med. 2011;6:10-14.

COMMENTARY

The top patient safety strategies that can be encouraged for adoption now.

Shekelle PG, Pronovost PJ, Wachter RM, et al. Ann Intern Med. 2013;158(5 Pt 2):365-368.

REVIEW

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

STUDY

What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.

Shearer B, Marshall S, Buist MD, et al. BMJ Qual Saf. 2012;21:569-575.

MULTI-USE WEBSITE

Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO).

Agency for Healthcare Quality and Research.

STUDY

Mortality rate after nonelective hospital admission.

Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Arch Surg. 2011;146:545-551.

BOOK/REPORT

National Healthcare Quality Reports.

Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0002.

TOOLKIT

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

BOOK/REPORT

Hospital Performance Report.

Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.

STUDY

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

Benin AL, Borgstrom CP, Jenq GY, Roumanis SA, Horwitz LI. BMJ Qual Saf. 2012;21:391-398.

TOOLKIT

Re-Engineered Discharge (RED) Toolkit.

Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.

REVIEW

Promoting a culture of safety as a patient safety strategy: a systematic review.

Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Ann Intern Med. 2013;158(5 Pt 2):369-374.

BOOK/REPORT classic

classic

Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report.

Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0030.

STUDY

Using care bundles to reduce in-hospital mortality: quantitative survey.

Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K. BMJ. 2010;340:c1234.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Medication reconciliation meets its MATCH.

Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

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