AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (112)

•Diagnostic Errors (177)

•Identification Errors (82)

•Discontinuities, Gaps, and Hand-Off Problems (327)

•Fatigue and Sleep Deprivation (67)

•Medication Safety (768)

•Medical Complications (397)

•Nonsurgical Procedural Complications (90)

•Surgical Complications (389)

•Transfusion Complications (15)

•Psychological and Social Complications (108)

Origin/Sponsor

•Africa (5)

•Asia (52)

•Australia and New Zealand (107)

•Central and South America (8)

•Europe (460)

•North America (2014)

Resource Types

•Audiovisual (15)

•Award (17)

•Book/Report (139)

•Clinical Guideline (4)

•Journal Article (2142)

•Legislation/Regulation (27)

•Meeting/Conference (26)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (129)

•Press Release/Announcement (18)

•Special or Theme Issue (49)

•Tools/Toolkit (41)

•Web Resource (82)

•Grant (11)

Error Types

•Epidemiology of Errors and Adverse Events (926)

•Active Errors (530)

•Latent Errors (185)

•Near Miss (65)

Approach to Improving Safety

•Quality Improvement Strategies (662)

•Legal and Policy Approaches (167)

•Error Reporting and Analysis (720)

•Communication Improvement (745)

•Human Factors Engineering (383)

•Teamwork (329)

•Specialization of Care (217)

•Logistical Approaches (189)

•Culture of Safety (540)

•Technologic Approaches (417)

•Education and Training (680)

Clinical Areas

•Allied Health Services (11)

•Complementary and Alternative Medicine (2)

Target Audience
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Health Care Providers

•Allied Health Professionals (7)

•Clinical Technologists (18)

Setting of Care

•Psychiatric Facilities (12)

•Residential Facilities (56)

•Ambulatory Care (260)

•Outpatient Surgery (23)

•Patient Transport (29)

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STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

STUDY

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Pediatrics. 2010;125:539-546.

STUDY

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Jt Comm J Qual Patient Saf. 2011;37:357-364.

STUDY

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

Percarpio KB, Harris FS, Hatfield BA, et al. Jt Comm J Qual Patient Saf. 2010;36:424-429:AP1.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Speaking up and sharing information improves trainee neonatal resuscitations.

Katakam LI, Trickey AW, Thomas EJ. J Patient Saf. 2012;8:202-209.

STUDY

Prevalence of adverse events in pediatric intensive care units in the United States.

Agarwal S, Classen D, Larsen G, et al. Pediatr Crit Care Med. 2010;11:568-578.

BOOK/REPORT classic

Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.

Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.

STUDY

Teamwork behaviours and errors during neonatal resuscitation.

Williams AL, Lasky RE, Dannemiller JL, Andrei AM, Thomas EJ. Qual Saf Health Care. 2010;19:60-64.

GRANT RECIPIENT

Improving Patient Safety Through Simulation Research.

Rockville, MD: Agency for Healthcare Research and Quality; June 2008.

STUDY

Measuring communication in the surgical ICU: better communication equals better care.

Williams M, Hevelone N, Alban RF, et al. J Am Coll Surg. 2010;210:17-22.

REVIEW

Patient safety in the NICU: a comprehensive review.

Samra HA, McGrath JM, Rollins W. J Perinat Neonatal Nurs. 2011;25:123-132.

REVIEW

Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review.

Merién AER, van de Ven J, Mol BW, Houterman S, Oei SG. Obstet Gynecol. 2010;115:1021-1031.

STUDY

Building collaborative teams in neonatal intensive care.

Brodsky D, Gupta M, Quinn M, et al. BMJ Qual Saf. 2013;374-382.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.

BOOK/REPORT

Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units.

Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN: 9780833050557.

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