AHRQ Patient Safety Network

The Collection > Health Care Executives and Administrators

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Safety Target

•Device-related Complications (149)

•Diagnostic Errors (138)

•Identification Errors (99)

•Discontinuities, Gaps, and Hand-Off Problems (541)

•Fatigue and Sleep Deprivation (76)

•Medication Safety (996)

•Medical Complications (423)

•Nonsurgical Procedural Complications (52)

•Surgical Complications (320)

•Transfusion Complications (18)

•Psychological and Social Complications (127)

Origin/Sponsor

•Africa (6)

•Asia (54)

•Australia and New Zealand (145)

•Central and South America (7)

•Europe (553)

•North America (2619)

Resource Types

•Clinical Guideline (2)

•Journal Article (2543)

•Legislation/Regulation (38)

•Meeting/Conference (35)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (300)

•Press Release/Announcement (24)

•Special or Theme Issue (63)

•Tools/Toolkit (46)

•Web Resource (98)

•Grant (12)

Error Types

•Epidemiology of Errors and Adverse Events (1067)

•Active Errors (453)

•Latent Errors (237)

•Near Miss (62)

Approach to Improving Safety

•Quality Improvement Strategies (889)

•Legal and Policy Approaches (394)

•Error Reporting and Analysis (1050)

•Communication Improvement (921)

•Human Factors Engineering (397)

•Teamwork (292)

•Specialization of Care (246)

•Logistical Approaches (257)

•Culture of Safety (557)

•Technologic Approaches (770)

•Education and Training (594)

Clinical Areas

•Allied Health Services (15)

Target Audience
< All

Health Care Executives and Administrators

•Facility and Group Administrators (238)

•Nurse Managers (198)

•Risk Managers (308)

•Quality and Safety Professionals (1262)

Setting of Care

•Hospitals (2476)

•Psychiatric Facilities (16)

•Residential Facilities (63)

•Ambulatory Care (291)

•Outpatient Surgery (31)

•Patient Transport (29)

1 - 20 of 3475

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STUDY

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial.

Graumlich JF, Novotny NL, Nace GS, et al. J Hosp Med. 2009;4:E11-E19.

STUDY

Information exchange among physicians caring for the same patient in the community.

van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.

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.

STUDY

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.

STUDY

Frequency and clinical importance of pages sent to the wrong physician.

Wong BM, Quan S, Cheung CM, et al. Arch Intern Med. 2009;169:1072-1073.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

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

COMMENTARY

Quality improvement through implementation of discharge order reconciliation.

Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.

STUDY

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

COMMENTARY

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

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

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

COMMENTARY

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Clarke D, Werestiuk K, Schoffner A, et al. J Nurs Manag. 2012;20:592-598.

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

Inpatient fall prevention: use of in-room Webcams.

Hardin SR, Dienemann J, Rudisill P, Mills KK. J Patient Saf. 2013;9:29-35.

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

Review of computerized physician handoff tools for improving the quality of patient care.

Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2012 Nov 20; [Epub ahead of print].

STUDY

Catching and correcting near misses: the collective vigilance and individual accountability trade-off.

Jeffs LP, Lingard L, Berta W, Baker GR. J Interprof Care. 2012;26:121-126.

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.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

STUDY

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

REVIEW

A systematic review of failures in handoff communication during intrahospital transfers.

Ong MS, Coiera E. Jt Comm J Qual Patient Saf. 2011;37:274-284.

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