AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (190)

•Diagnostic Errors (177)

•Identification Errors (126)

•Discontinuities, Gaps, and Hand-Off Problems (580)

•Fatigue and Sleep Deprivation (110)

•Medication Safety (1186)

•Medical Complications (519)

•Nonsurgical Procedural Complications (94)

•Surgical Complications (451)

•Transfusion Complications (20)

•Psychological and Social Complications (166)

Origin/Sponsor

•Australia and New Zealand (142)

•Central and South America (7)

•Europe (545)

•North America (3567)

Resource Types

•Audiovisual (31)

•Bibliography (3)

•Book/Report (293)

•Clinical Guideline (4)

•Journal Article (3244)

•Legislation/Regulation (61)

•Meeting/Conference (41)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (399)

•Press Release/Announcement (28)

•Special or Theme Issue (73)

•Tools/Toolkit (60)

•Web Resource (110)

Error Types

•Epidemiology of Errors and Adverse Events (1183)

•Active Errors (571)

•Latent Errors (271)

•Near Miss (80)

Approach to Improving Safety

•Quality Improvement Strategies (1161)

•Legal and Policy Approaches (495)

•Error Reporting and Analysis (1346)

•Communication Improvement (1152)

•Human Factors Engineering (512)

•Teamwork (396)

•Specialization of Care (325)

•Logistical Approaches (332)

•Culture of Safety (720)

•Technologic Approaches (757)

•Education and Training (785)

Clinical Areas

•Allied Health Services (15)

•Dentistry (2)

•Medicine (2906)

•Nursing (368)

•Pharmacy (409)

Target Audience
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Health Care Executives and Administrators

•Facility and Group Administrators (363)

•Nurse Managers (343)

•Risk Managers (532)

•Quality and Safety Professionals (1724)

Setting of Care

•Hospitals (2981)

•Psychiatric Facilities (19)

•Residential Facilities (78)

•Ambulatory Care (367)

•Outpatient Surgery (41)

•Patient Transport (35)

1 - 20 of 4410

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REVIEW

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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.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

STUDY

classic

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.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

BOOK/REPORT

Managing Patients' Medicines after Discharge from Hospital.

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

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.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

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

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.

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.

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.

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].

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

STUDY

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

McDonald KM, Davies SM, Haberland CA, et al. Pediatrics. 2008;122:e416-e425.

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.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

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