AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (143)

•Diagnostic Errors (181)

•Identification Errors (102)

•Discontinuities, Gaps, and Hand-Off Problems (449)

•Fatigue and Sleep Deprivation (94)

•Medication Safety (1077)

•Medical Complications (410)

•Nonsurgical Procedural Complications (90)

•Surgical Complications (382)

•Transfusion Complications (14)

•Psychological and Social Complications (159)

Origin/Sponsor

•Africa (6)

•Asia (32)

•Australia and New Zealand (95)

•Central and South America (6)

•Europe (380)

•North America (3084)

Resource Types

•Clinical Guideline (10)

•Journal Article (2610)

•Legislation/Regulation (62)

•Meeting/Conference (34)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (330)

•Press Release/Announcement (30)

•Special or Theme Issue (70)

•Tools/Toolkit (68)

•Web Resource (131)

•Grant (12)

Error Types

•Epidemiology of Errors and Adverse Events (750)

•Active Errors (561)

•Latent Errors (250)

•Near Miss (68)

Approach to Improving Safety

•Quality Improvement Strategies (896)

•Legal and Policy Approaches (351)

•Error Reporting and Analysis (964)

•Communication Improvement (1027)

•Human Factors Engineering (448)

•Teamwork (387)

•Specialization of Care (278)

•Logistical Approaches (278)

•Culture of Safety (601)

•Technologic Approaches (618)

•Education and Training (727)

Clinical Areas

•Allied Health Services (14)

Target Audience
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Health Care Providers

•Allied Health Professionals (9)

•Clinical Technologists (29)

Setting of Care

•Psychiatric Facilities (17)

•Residential Facilities (68)

•Ambulatory Care (399)

•Outpatient Surgery (39)

•Patient Transport (31)

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BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

COMMENTARY

Learning accountability for patient outcomes.

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

STUDY

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

MULTI-USE WEBSITE

BOOSTing Care Transitions Resource Room.

Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.

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.

STUDY

Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.

Clarke S. J Occup Organ Psychol. 2013;86:22-49.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

SPECIAL OR THEME ISSUE

Front-Line Ownership: Generating a Cure Mindset for Patient Safety.

Kitts J, ed. Healthcare Papers. 2013;13:1-82.

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.

STUDY

The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study.

Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. Infect Control Hosp Epidemiol. 2010;31:901-907.

STUDY

Analysis of staff safety concerns.

Davidson J, Lamontagne G, Burnell L, et al. J Nurs Care Qual. 2013;28:147-152.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

BOOK/REPORT classic

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

BOOK/REPORT

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.

Koppel R, Gordon S, ed. Ithaca, NY: Cornell University Press; 2012. ISBN: 9780801450778.

STUDY

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

COMMENTARY

Frontline hospital workers and the worker safety/patient safety nexus.

Sokas R, Braun B, Chenven L, et al. Jt Comm J Qual Patient Saf. 2013;39:185-192.

STUDY

Measurement for improvement: a survey of current practice in Australian public hospitals.

Brand CA, Tropea J, Ibrahim JE, et al. Med J Aust. 2008;189:35-40.

STUDY

Attitude is everything?: The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units.

Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G. Health Care Manage Rev. 2012 Oct 18; [Epub ahead of print].

BOOK/REPORT

Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.

Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058.

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