AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (110)

•Diagnostic Errors (84)

•Identification Errors (67)

•Discontinuities, Gaps, and Hand-Off Problems (174)

•Fatigue and Sleep Deprivation (18)

•Medication Safety (529)

•Medical Complications (309)

•Nonsurgical Procedural Complications (61)

•Surgical Complications (264)

•Transfusion Complications (12)

•Psychological and Social Complications (41)

Origin/Sponsor

•Africa (4)

•Asia (26)

•Australia and New Zealand (62)

•Central and South America (6)

•Europe (470)

•North America (1056)

Resource Types

•Audiovisual (8)

•Award (6)

•Book/Report (90)

•Clinical Guideline (3)

•Journal Article (1276)

•Legislation/Regulation (24)

•Meeting/Conference (16)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (97)

•Press Release/Announcement (20)

•Special or Theme Issue (31)

•Tools/Toolkit (17)

•Web Resource (48)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (451)

•Active Errors (380)

•Latent Errors (117)

•Near Miss (38)

Approach to Improving Safety

•Quality Improvement Strategies (446)

•Legal and Policy Approaches (83)

•Error Reporting and Analysis (392)

•Communication Improvement (463)

•Human Factors Engineering (440)

•Teamwork (181)

•Specialization of Care (119)

•Logistical Approaches (98)

•Culture of Safety (209)

•Technologic Approaches (276)

•Education and Training (340)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (1)

•Clinical Technologists (3)

Setting of Care

•Psychiatric Facilities (10)

•Residential Facilities (28)

•Ambulatory Care (152)

•Outpatient Surgery (17)

•Patient Transport (17)

1 - 20 of 1643

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STUDY

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.

Longmate AG, Ellis KS, Boyle L, et al. BMJ Qual Saf. 2011;20:174-180.

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

COMMENTARY

Emerging infections: the contact precautions controversy.

Zastrow RL. Am J Nurs. 2011;111:47-53.

STUDY

Nursing and physician attire as possible source of nosocomial infections.

Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Am J Infect Control. 2011;39:555-559.

REVIEW

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

Burnett E, Kearney N, Johnston B, Corlett J, Macgillivray S. Am J Infect Control. 2013;41:394-400.

MULTI-USE WEBSITE

One & Only Campaign.

Centers for Disease Control and Prevention, Safe Injection Practices Coalition.

STUDY

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.

Smith AF, Casey K, Wilson J, Fischbacher-Smith D. Int J Qual Health Care. 2011;23:590-599.

ORGANIZATIONAL POLICY/GUIDELINES

Standardising wristbands improves patient safety.

Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

STUDY

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. Ergonomics. 2011;54:21-33.

STUDY

The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.

Oake N, Taljaard M, van Walraven C, Wilson K, Roth V, Forster AJ. Arch Intern Med. 2010;170:1804-1810.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

BOOK/REPORT

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

REVIEW

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.

Backman C, Zoutman DE, Marck PB. Am J Infect Control. 2008;36:333-348.

STUDY

Practically speaking: rethinking hand hygiene improvement programs in health care settings.

Son C, Chuck T, Childers T, et al. Am J Infect Control. 2011;39:716-724.

STUDY

Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative.

Pinto A, Burnett S, Benn J, et al. J Eval Clin Pract. 2011;17:180-187.

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