AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (142)

•Diagnostic Errors (295)

•Identification Errors (103)

•Discontinuities, Gaps, and Hand-Off Problems (450)

•Fatigue and Sleep Deprivation (106)

•Medication Safety (1100)

•Medical Complications (368)

•Nonsurgical Procedural Complications (94)

•Surgical Complications (353)

•Transfusion Complications (14)

•Psychological and Social Complications (123)

Origin/Sponsor

•Africa (2)

•Asia (40)

•Australia and New Zealand (70)

•Central and South America (7)

•Europe (315)

•North America (3011)

Resource Types

•Clinical Guideline (9)

•Journal Article (2573)

•Legislation/Regulation (55)

•Meeting/Conference (29)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (305)

•Press Release/Announcement (35)

•Special or Theme Issue (55)

•Tools/Toolkit (60)

•Web Resource (101)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (823)

•Active Errors (660)

•Latent Errors (244)

•Near Miss (76)

Approach to Improving Safety

•Quality Improvement Strategies (846)

•Legal and Policy Approaches (330)

•Error Reporting and Analysis (1101)

•Communication Improvement (924)

•Human Factors Engineering (434)

•Teamwork (256)

•Specialization of Care (251)

•Logistical Approaches (284)

•Culture of Safety (415)

•Technologic Approaches (601)

•Education and Training (672)

Clinical Areas

•Allied Health Services (12)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (8)

•Clinical Technologists (39)

Setting of Care

•Psychiatric Facilities (20)

•Residential Facilities (60)

•Ambulatory Care (415)

•Outpatient Surgery (39)

•Patient Transport (28)

1 - 20 of 3517

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NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.

STUDY

The cost of pneumonia after acute stroke.

Katzan IL, Dawson NV, Thomas CL, Votruba ME, Cebul RD. Neurology. 2007;68:1938-1943.

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

BOOK/REPORT

Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.

Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.

BOOK/REPORT

Patient Safety in Canada: An Update.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

BOOK/REPORT

Hospital Reporting Program.

Portland, OR: Oregon Patient Safety Commission.

STUDY

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

Spector WD, Mutter R, Owens P, Limcangco R. Med Care. 2012;50:863-869.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

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.

STUDY

Medical errors in US pediatric inpatients with chronic conditions.

Ahuja N, Zhao W, Xiang H. Pediatrics. 2012;130:e786-e793.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

NEWSPAPER/MAGAZINE ARTICLE

Massachusetts hospitals launch patient apology program.

Gallegos A. American Medical News. May 21, 2012.

STUDY

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. J Gen Intern Med. 2012;27:1416-1423.

STUDY

Anticoagulation-associated adverse drug events.

Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.

STUDY

Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients.

Fagan K, Sabel A, Mehler PS, MacKenzie TD. Am J Med Qual. 2012;27:480-486.

FACT SHEET/FAQS

10 Tips to Help Promote Patient Safety.

Chicago, IL: American Society for Healthcare Risk Management; 2013.

COMMENTARY

No Blood, Please.

Liang BA. AHRQ WebM&M [serial online]. May 2004.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

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