AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (153)

•Diagnostic Errors (147)

•Identification Errors (111)

•Discontinuities, Gaps, and Hand-Off Problems (556)

•Fatigue and Sleep Deprivation (89)

•Medication Safety (1008)

•Medical Complications (450)

•Nonsurgical Procedural Complications (74)

•Surgical Complications (380)

•Transfusion Complications (17)

•Psychological and Social Complications (147)

Origin/Sponsor

•Australia and New Zealand (110)

•Central and South America (4)

•Europe (439)

•North America (3204)

Resource Types

•Audiovisual (29)

•Bibliography (3)

•Book/Report (277)

•Clinical Guideline (3)

•Journal Article (2777)

•Legislation/Regulation (52)

•Meeting/Conference (40)

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•Newspaper/Magazine Article (367)

•Press Release/Announcement (25)

•Special or Theme Issue (74)

•Tools/Toolkit (52)

•Web Resource (108)

Error Types

•Epidemiology of Errors and Adverse Events (815)

•Active Errors (474)

•Latent Errors (242)

•Near Miss (60)

Approach to Improving Safety

•Quality Improvement Strategies (1031)

•Legal and Policy Approaches (463)

•Error Reporting and Analysis (1107)

•Communication Improvement (1100)

•Human Factors Engineering (457)

•Teamwork (368)

•Specialization of Care (271)

•Logistical Approaches (273)

•Culture of Safety (677)

•Technologic Approaches (818)

•Education and Training (702)

Clinical Areas

•Allied Health Services (14)

•Dentistry (1)

•Medicine (2563)

•Nursing (241)

•Pharmacy (346)

Target Audience
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Health Care Executives and Administrators

•Facility and Group Administrators (260)

•Nurse Managers (203)

•Risk Managers (375)

•Quality and Safety Professionals (1385)

Setting of Care

•Hospitals (2449)

•Psychiatric Facilities (17)

•Residential Facilities (69)

•Ambulatory Care (309)

•Outpatient Surgery (35)

•Patient Transport (29)

1 - 20 of 3871

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REVIEW

The efficacy of computer-enabled discharge communication interventions: a systematic review.

Motamedi SM, Posadas-Calleja J, Straus S, et al. BMJ Qual Saf. 2011;20:403-415.

STUDY

classic

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

STUDY

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

Mohta N, Vaishnava P, Liang C, et al. BMJ Qual Saf. 2012;21:885-890.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

REVIEW

classic

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.

Zsenits B, Polashenski WA, Sterns RH, Brown DR IV, Moheet A. J Hosp Med. 2009;4:308-312.

STUDY

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. J Hosp Med. 2011;6:329-337.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

Design and implementation of an automated email notification system for results of tests pending at discharge.

Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.

STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals boost patients' power as advisers.

Landro L. Wall Street Journal. August 8, 2007:D1.

REVIEW

classic

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

MULTI-USE WEBSITE

BOOSTing Care Transitions Resource Room.

Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.

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