AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (125)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (100)

•Fatigue and Sleep Deprivation (67)

•Medication Safety (177)

•Medical Complications (28)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (135)

•Transfusion Complications (1)

•Psychological and Social Complications (34)

Origin/Sponsor

•Asia (16)

•Australia and New Zealand (24)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (666)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (43)

•Press Release/Announcement (3)

•Special or Theme Issue (4)

•Tools/Toolkit (3)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (269)

•Active Errors (147)

•Latent Errors (29)

•Near Miss (10)

Approach to Improving Safety

•Quality Improvement Strategies (138)

•Legal and Policy Approaches (41)

•Error Reporting and Analysis (234)

•Communication Improvement (159)

•Human Factors Engineering (59)

•Teamwork (49)

•Specialization of Care (34)

•Logistical Approaches (92)

•Culture of Safety (46)

•Technologic Approaches (102)

•Education and Training (222)

Clinical Areas

•Medicine (586)

•Nursing (15)

•Pharmacy (52)

Target Audience
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Physicians

Setting of Care

•Hospitals (437)

•Psychiatric Facilities (1)

•Residential Facilities (4)

•Ambulatory Care (61)

•Outpatient Surgery (9)

•Patient Transport (2)

1 - 20 of 757

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STUDY

Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam.

Sibbald M, de Bruin AB, Cavalcanti RB, van Merrienboer JJ. BMJ Qual Saf. 2013;22:333-338.

STUDY

Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.

Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304:1198-1203.

STUDY

Misleading one detail: a preventable mode of diagnostic error?

Arzy S, Brezis M, Khoury S, Simon SR, Ben-Hur T. J Eval Clin Pract. 2009;15:804-806.

COMMENTARY

Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs.

Ilgen JS, Humbert AJ, Kuhn G, et al. Acad Emerg Med. 2012;19:1454-1461.

STUDY

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. Anesth Analg. 2013;116:892-897.

STUDY

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

Types and origins of diagnostic errors in primary care settings.

Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. JAMA Intern Med. 2013;173:418-425.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

STUDY

Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?

Sibbald M, De Bruin ABH, van Merrienboer JJG. Adv Health Sci Educ Theory Pract. 2013 Apr 27; [Epub ahead of print].

STUDY

Checklists improve experts' diagnostic decisions.

Sibbald M, de Bruin ABH, van Merrienboer JJG. Med Educ. 2013;47:301-308.

COMMENTARY classic

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-598.

STUDY

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia: [L'observation de mesures simples et efficaces reduit l'incidence de pneumonie associee a la ventilation mecanique].

Baxter AD, Allan J, Bedard J, et al. Can J Anaesth. 2005;52:535-541.

STUDY

The impact of video games on training surgeons in the 21st century.

Rosser JC Jr, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. Arch Surg. 2007;142:181-186.

COMMENTARY

"Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist?

Benbadis SR. Neurology. 2013;80(suppl 1):S47-S51.

COMMENTARY

A model for building a standardized hand-off protocol.

Arora V, Johnson J. Jt Comm J Qual Patient Saf. 2006;32:646-655.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

STUDY

A patient safety curriculum for medical residents based on the perspectives of residents and supervisors.

Jansma JD, Wagner C, Bijnen AB. J Patient Saf. 2011;7:99-105.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

COMMENTARY

Physical Diagnosis: A Lost Art?

Thompson GR, Verghese A. AHRQ WebM&M [serial online]. August 2006.

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