AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (88)

•Diagnostic Errors (168)

•Identification Errors (74)

•Discontinuities, Gaps, and Hand-Off Problems (212)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (640)

•Medical Complications (221)

•Nonsurgical Procedural Complications (68)

•Surgical Complications (283)

•Transfusion Complications (12)

•Psychological and Social Complications (70)

Origin/Sponsor

•Africa (7)

•Asia (38)

•Australia and New Zealand (67)

•Central and South America (7)

•Europe (505)

•North America (1410)

Resource Types

•Clinical Guideline (3)

•Journal Article (1559)

•Legislation/Regulation (30)

•Meeting/Conference (21)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (127)

•Press Release/Announcement (25)

•Special or Theme Issue (29)

•Tools/Toolkit (26)

•Web Resource (51)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (916)

•Active Errors (362)

•Latent Errors (141)

•Near Miss (49)

Approach to Improving Safety

•Quality Improvement Strategies (508)

•Legal and Policy Approaches (243)

•Error Reporting and Analysis (819)

•Communication Improvement (467)

•Human Factors Engineering (261)

•Teamwork (162)

•Specialization of Care (100)

•Logistical Approaches (178)

•Culture of Safety (463)

•Technologic Approaches (319)

•Education and Training (328)

Clinical Areas

•Allied Health Services (7)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (4)

•Clinical Technologists (55)

Setting of Care

•Psychiatric Facilities (16)

•Residential Facilities (46)

•Ambulatory Care (232)

•Outpatient Surgery (22)

•Patient Transport (24)

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COMMENTARY

Improving patient safety in radiotherapy by learning from near misses, incidents and errors.

Williams MV. Br J Radiol. 2007;80:297-301.

COMMENTARY

Accident prevention in day-to-day clinical radiation therapy practice.

Baeza M. Ann ICRP. 2012;41:179-187.

STUDY

Undiagnosed breast cancer at MR imaging: analysis of causes.

Pages EB, Millet I, Hoa D, Doyon FC, Taourel P. Radiology. 2012;264:40-50.

STUDY

Quantitative assessment of workload and stressors in clinical radiation oncology.

Mazur LM, Mosaly PR, Jackson M, et al. Int J Radiat Oncol Biol Phys. 2012;83:e571-e576.

BOOK/REPORT

Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.

Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.

REVIEW

Clinical errors and medical negligence.

Oyebode F. Med Princ Pract. 2013 Jan 18; [Epub ahead of print].

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

STUDY

Modern palliative radiation treatment: do complexity and workload contribute to medical errors?

D'Souza N, Holden L, Robson S, et al. Int J Radiat Oncol Biol Phys. 2012;84:e43-e48.

COMMENTARY

Patient safety in cataract surgery.

Kelly SP, Astbury NJ. Eye. 2006;20:275-282.

STUDY

Venous thromboembolism after trauma: a never event?

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

REVIEW

Radiologic errors and malpractice: a blurry distinction.

Berlin L. AJR Am J Roentgenol. 2007;189:517-522.

STUDY

CT for suspected appendicitis in children: an analysis of diagnostic errors.

Taylor GA, Callahan MJ, Rodriguez D, Smink DS. Pediatr Radiol. 2006;36:331-337.

COMMENTARY

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

STUDY

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84:1602-1609.

BOOK/REPORT

Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report.

The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.

STUDY

Analysis of risk factors for adverse drug events in critically ill patients.

Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Crit Care Med. 2012;40:823-828.

STUDY

Safety culture and complications after bariatric surgery.

Birkmeyer NJ, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-265.

REVIEW

Systematic review of medication errors in pediatric patients.

Ghaleb MA, Barber N, Franklin BD, Yeung VW, Khaki ZF, Wong IC. Ann Pharmacother. 2006;40:1766-1776.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

PRESS RELEASE/ANNOUNCEMENT

CT brain perfusion scans safety investigation: initial notification.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

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