AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (124)

•Diagnostic Errors (165)

•Identification Errors (90)

•Discontinuities, Gaps, and Hand-Off Problems (383)

•Fatigue and Sleep Deprivation (88)

•Medication Safety (853)

•Medical Complications (368)

•Nonsurgical Procedural Complications (94)

•Surgical Complications (343)

•Transfusion Complications (17)

•Psychological and Social Complications (89)

Origin/Sponsor

•Africa (5)

•Asia (50)

•Australia and New Zealand (104)

•Central and South America (8)

•Europe (476)

•North America (2156)

Resource Types

•Audiovisual (14)

•Award (20)

•Book/Report (154)

•Clinical Guideline (5)

•Journal Article (2195)

•Legislation/Regulation (39)

•Meeting/Conference (23)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (196)

•Press Release/Announcement (26)

•Special or Theme Issue (52)

•Tools/Toolkit (45)

•Web Resource (87)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (711)

•Active Errors (553)

•Latent Errors (221)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (702)

•Legal and Policy Approaches (200)

•Error Reporting and Analysis (787)

•Communication Improvement (811)

•Human Factors Engineering (393)

•Teamwork (293)

•Specialization of Care (226)

•Logistical Approaches (223)

•Culture of Safety (545)

•Technologic Approaches (469)

•Education and Training (727)

Clinical Areas

•Allied Health Services (10)

•Complementary and Alternative Medicine (2)

Target Audience
< All

Health Care Providers

•Allied Health Professionals (3)

•Clinical Technologists (16)

Setting of Care

•Psychiatric Facilities (15)

•Residential Facilities (58)

•Ambulatory Care (298)

•Outpatient Surgery (27)

•Patient Transport (20)

1 - 20 of 2866

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TOOLKIT

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

Washington, DC: US Department of Health and Human Services; May 2011.

REVIEW

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.

COMMENTARY

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.

NEWSPAPER/MAGAZINE ARTICLE

That’s the way we do things around here!

ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

STUDY

Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands.

Leendertse AJ, Egberts ACG, Stoker LJ, van den Bemt PMLA, for the HARM Study Group. Arch Intern Med. 2008;168:1890-1896.

COMMENTARY

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

Melnyk BM. Nurs Adm Q. 2012;36:127-135.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

TOOLKIT

CUSP Toolkit.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

STUDY

A systems approach to morbidity and mortality conference.

Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.

STUDY

Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital.

Karapinar-Çarkit F, Borgsteede SD, Zoer J, Smit HJ, Egberts ACG, van den Bemt PMLA. Ann Pharmacother. 2009;43:1001-1010.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Perceptions of hospital safety climate and incidence of readmission.

Hansen LO, Williams MV, Singer SJ. Health Serv Res. 2011;46:596-616.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

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