AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (35)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (142)

•Fatigue and Sleep Deprivation (21)

•Medication Safety (184)

•Medical Complications (24)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (123)

•Transfusion Complications (2)

•Psychological and Social Complications (8)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (22)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (464)

•Legislation/Regulation (12)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (60)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (11)

•Web Resource (9)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (100)

•Active Errors (80)

•Latent Errors (39)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (171)

•Legal and Policy Approaches (33)

•Error Reporting and Analysis (133)

•Communication Improvement (186)

•Human Factors Engineering (69)

•Teamwork (66)

•Specialization of Care (22)

•Logistical Approaches (41)

•Culture of Safety (39)

•Technologic Approaches (81)

•Education and Training (150)

Clinical Areas

•Allied Health Services (2)

•Medicine (460)

•Nursing (45)

•Pharmacy (48)

Target Audience
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Physicians

Setting of Care

•Hospitals (363)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (40)

•Outpatient Surgery (6)

•Patient Transport (2)

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COMMENTARY

In situ simulation: a method of experiential learning to promote safety and team behavior.

Miller KK, Riley W, Davis S, Hansen HE. J Perinat Neonatal Nurs. 2008;22:105-113.

COMMENTARY

DNR in the OR and Afterwards

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

STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

SPECIAL OR THEME ISSUE

The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise.

Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.

STUDY

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

Paige J, Kozmenko V, Morgan B, et al. J Surg Educ. 2007;64:369-377.

COMMENTARY

Crises in clinical care: an approach to management.

Runciman WB, Merry AF. Qual Saf Health Care. 2005;14:156-163.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

STUDY

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.'

Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-633.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: what can medicine learn from aviation?

O'Reilly KB. American Medical News. June 14, 2010.

COMMENTARY

Discharge Against Medical Advice.

Hwang SW. WebM&M [serial online]. May 2005.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

REVIEW

Navigating towards improved surgical safety using aviation-based strategies.

Kao LS, Thomas EJ. J Surg Res. 2008;145:327-335.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.

STUDY

Simulation-based medical error disclosure training for pediatric healthcare professionals.

Wayman KI, Yaeger KA, Sharek PJ, et al. J Healthc Qual. 2007;29:12-19.

STUDY

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

Haan JM, Dutton RP, Willis M, Leone S, Kramer ME, Scalea TM. J Trauma. 2007;63:339-343.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

Shute N. U.S. News & World Report. January 23, 2006;140:62-63.

COMMENTARY

Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.

Runciman WB, Kluger MT, Morris RW, Paix AD, Watterson LM, Webb RK. Qual Saf Health Care. 2005;14:e1.

STUDY

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

Giesen P, Ferwerda R, Tijssen R, et al. Qual Saf Health Care. 2007;16:181-184.

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