AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (40)

•Diagnostic Errors (8)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (82)

•Fatigue and Sleep Deprivation (15)

•Medication Safety (277)

•Medical Complications (70)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (78)

•Transfusion Complications (2)

•Psychological and Social Complications (17)

Origin/Sponsor

•Asia (22)

•Australia and New Zealand (25)

•Central and South America (3)

Resource Types

•Clinical Guideline (5)

•Journal Article (556)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (63)

•Press Release/Announcement (8)

•Special or Theme Issue (7)

•Tools/Toolkit (12)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (148)

•Active Errors (100)

•Latent Errors (52)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (207)

•Legal and Policy Approaches (26)

•Error Reporting and Analysis (154)

•Communication Improvement (167)

•Human Factors Engineering (89)

•Teamwork (75)

•Specialization of Care (38)

•Logistical Approaches (74)

•Culture of Safety (85)

•Technologic Approaches (97)

•Education and Training (126)

Clinical Areas

•Allied Health Services (3)

•Medicine (403)

•Nursing (305)

•Pharmacy (63)

Target Audience
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Nurses

Setting of Care

•Hospitals (492)

•Psychiatric Facilities (4)

•Residential Facilities (16)

•Ambulatory Care (34)

•Outpatient Surgery (3)

•Patient Transport (2)

1 - 20 of 690

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COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

REVIEW

Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.

Johnson JR, Kuskowski MA, Wilt TJ. Ann Intern Med. 2006;144:116-126.

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

NEWSPAPER/MAGAZINE ARTICLE

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

COMMENTARY

Hidden Mystery.

Brunette DD. AHRQ WebM&M [serial online]. March 2005.

STUDY

The incidence and severity of adverse events affecting patients after discharge from the hospital.

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:161-167.

BOOK/REPORT

Recommendations for Safe Use of Insulin in Hospitals.

Bethesda, MD: American Society of Health-System Pharmacists; 2006.

COMMENTARY

Improving patient safety in critical care: big challenge, exciting opportunity/L'amelioration de la securite des patients a l'unite des soins intensifs : un grand defi, une occasion stimulante.

Dodek P. Can J Anaesth. 2005;52:459-462.

ORGANIZATIONAL POLICY/GUIDELINES

Safe use of opioids in hospitals.

Sentinel Event Alert. August 8, 2012;(49):1-5.

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.

COMMENTARY

Best-practice protocols: Preventing adverse drug events.

Weir VL. Nurs Manage. 2005;36:24-30.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

ORGANIZATIONAL POLICY/GUIDELINES

Tubing misconnections—a persistent and potentially deadly occurrence.

Sentinel Event Alert. April 3, 2006;(36):1-3.

STUDY

Safety of patients isolated for infection control.

Stelfox HT, Bates DW, Redelmeier DA. JAMA. 2003;290:1899-1905.

REVIEW

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.

Poissant L, Pereira J, Tamblyn R, Kawasumi Y. J Am Med Inform Assoc. 2005;12:505-516.

COMMENTARY

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.

STUDY

Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes.

Chern CH, How CK, Wang LM, Lee CH, Graff L. Ann Emerg Med 2005;45:15-23.

STUDY

Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.

Maragakis LL, Bradley KL, Song X, et al. Infect Control Hosp Epidemiol. 2006;27:67-70.

STUDY

Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution.

Lankshear AJ, Sheldon TA, Lowson KV, Watt IS, Wright J. Qual Saf Health Care. 2005;14:196-201.

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