AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (65)

•Diagnostic Errors (70)

•Identification Errors (56)

•Discontinuities, Gaps, and Hand-Off Problems (194)

•Fatigue and Sleep Deprivation (36)

•Medication Safety (484)

•Medical Complications (217)

•Nonsurgical Procedural Complications (43)

•Surgical Complications (177)

•Transfusion Complications (10)

•Psychological and Social Complications (66)

Origin/Sponsor

•Africa (6)

•Asia (25)

•Australia and New Zealand (70)

•Central and South America (5)

•Europe (248)

•North America (1342)

Resource Types

•Clinical Guideline (1)

•Journal Article (1100)

•Legislation/Regulation (25)

•Meeting/Conference (30)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (165)

•Press Release/Announcement (31)

•Special or Theme Issue (45)

•Tools/Toolkit (42)

•Web Resource (92)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (311)

•Active Errors (225)

•Latent Errors (124)

•Near Miss (36)

Approach to Improving Safety

•Quality Improvement Strategies (514)

•Legal and Policy Approaches (239)

•Error Reporting and Analysis (615)

•Communication Improvement (488)

•Human Factors Engineering (218)

•Teamwork (186)

•Specialization of Care (120)

•Logistical Approaches (113)

•Culture of Safety (474)

•Technologic Approaches (290)

•Education and Training (353)

Clinical Areas

•Allied Health Services (10)

•Complementary and Alternative Medicine (2)

Target Audience
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Health Care Providers

•Allied Health Professionals (2)

•Clinical Technologists (8)

Setting of Care

•Psychiatric Facilities (13)

•Residential Facilities (42)

•Ambulatory Care (159)

•Outpatient Surgery (22)

•Patient Transport (15)

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COMMENTARY

In Conversation with...James P. Bagian, MD

AHRQ WebM&M [serial online]. September 2006.

COMMENTARY

Patient safety: lessons learned.

Bagian JP. Pediatr Radiol. 2006;36:287-290.

STUDY

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.

Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.

MULTI-USE WEBSITE

National Center for Patient Safety (NCPS).

Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

COMMENTARY

Implementing patient safety initiatives in rural hospitals.

Klingner J, Moscovice I, Tupper J, Coburn A, Wakefield M. J Rural Health. 2009;25:352-357.

NEWSPAPER/MAGAZINE ARTICLE

Global goal: reduce medical errors.

Szabo L. USA Today. August 23, 2005.

STUDY

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. Jt Comm J Qual Patient Saf. 2009;35:239-246.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

STUDY

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.

Mills PD, Neily J, Luan D, Osborne A, Howard K. Jt Comm J Qual Patient Saf. 2006;32:130-141.

STUDY

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

STUDY

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.

COMMENTARY

Patient safety: what is really at issue?

Bagian JP. Front Health Serv Manage. Fall 2005;22:3-16.

MULTI-USE WEBSITE

National Patient Safety Awareness Week.

National Patient Safety Foundation.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.

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.

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