AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (178)

•Diagnostic Errors (254)

•Identification Errors (126)

•Discontinuities, Gaps, and Hand-Off Problems (527)

•Fatigue and Sleep Deprivation (121)

•Medication Safety (1315)

•Medical Complications (452)

•Nonsurgical Procedural Complications (118)

•Surgical Complications (507)

•Transfusion Complications (17)

•Psychological and Social Complications (171)

Origin/Sponsor

•Africa (6)

•Asia (63)

•Australia and New Zealand (124)

•Central and South America (9)

•Europe (502)

•North America (3452)

Resource Types

•Clinical Guideline (10)

•Journal Article (3214)

•Legislation/Regulation (64)

•Meeting/Conference (23)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (351)

•Press Release/Announcement (36)

•Special or Theme Issue (71)

•Tools/Toolkit (65)

•Web Resource (116)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (950)

•Active Errors (793)

•Latent Errors (298)

•Near Miss (90)

Approach to Improving Safety

•Quality Improvement Strategies (995)

•Legal and Policy Approaches (353)

•Error Reporting and Analysis (1096)

•Communication Improvement (1188)

•Human Factors Engineering (601)

•Teamwork (382)

•Specialization of Care (298)

•Logistical Approaches (351)

•Culture of Safety (530)

•Technologic Approaches (706)

•Education and Training (847)

Clinical Areas

•Allied Health Services (12)

Target Audience
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Health Care Providers

•Allied Health Professionals (11)

•Clinical Technologists (37)

Setting of Care

•Psychiatric Facilities (22)

•Residential Facilities (79)

•Ambulatory Care (445)

•Outpatient Surgery (46)

•Patient Transport (36)

1 - 20 of 4256

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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.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

COMMENTARY

Using simulation to teach nursing students and licensed clinicians obstetric emergencies.

Alderman JT. MCN Am J Matern Child Nurs. 2012;37:394-400.

STUDY

Medication safety initiative in reducing medication errors.

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

COMMENTARY

Learning accountability for patient outcomes.

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

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.

Clare CA, Afzal O, Knapp K, Viola D. J Patient Saf. 2013;9:68-74.

STUDY

Improving teamwork on general medical units: when teams do not work face-to-face.

McComb SA, Henneman EA, Hinchey KT, et al. Jt Comm J Qual Patient Saf. 2012;38:471-478.

STUDY

Perceptions of effective and ineffective nurse–physician communication in hospitals.

Robinson FP, Gorman G, Slimmer LW, Yudkowsky R. Nurs Forum. 2010;45:206-216.

STUDY

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting.

Makowsky MJ, Schindel TJ, Rosenthal M, Campbell K, Tsuyuki RT, Madill HM. J Interprof Care. 2009;23:169-84.

COMMENTARY

The role of nursing surveillance in keeping patients safe.

Dresser S. J Nurs Adm. 2012;42:361-368.

BOOK/REPORT

Fostering Organizational Learning: The Impact of Work Design on Workarounds, Errors, and Speaking Up About Internal Supply Chain Problems.

Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. HBS Working Paper No. 13-044.

STUDY

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

Mohta N, Vaishnava P, Liang C, et al. BMJ Qual Saf. 2012;21:885-890.

NEWSPAPER/MAGAZINE ARTICLE

Your high-alert medication list—relatively useless without associated risk-reduction strategies.

ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

COMMENTARY

Ticket to ride: reducing handoff risk during hospital patient transport.

Pesanka DA, Greenhouse PK, Rack LL, et al. J Nurs Care Qual. 2009;24:109-115.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens.

Göbel B, Zwart D, Hesselink G, Pijnenborg L, Barach P, Kalkman C, Johnson JK. BMJ Qual Saf. 2012;21:i106-i113.

STUDY

Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response.

Murtagh L, Gallagher TH, Andrew P, Mello MM. Health Aff (Millwood). 2012;31:2681-2689.

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