AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (20)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (55)

•Fatigue and Sleep Deprivation (22)

•Medication Safety (116)

•Medical Complications (31)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (35)

•Transfusion Complications (3)

•Psychological and Social Complications (11)

Origin/Sponsor

•Australia and New Zealand (21)

•North America (289)

Resource Types

•Book/Report (22)

•Journal Article (308)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (41)

•Press Release/Announcement (1)

•Special or Theme Issue (4)

•Tools/Toolkit (9)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (96)

•Active Errors (37)

•Latent Errors (45)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (125)

•Legal and Policy Approaches (38)

•Error Reporting and Analysis (168)

•Communication Improvement (82)

•Human Factors Engineering (34)

•Teamwork (31)

•Specialization of Care (30)

•Logistical Approaches (44)

•Culture of Safety (78)

•Technologic Approaches (86)

•Education and Training (61)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

•Medicine (242)

•Nursing (23)

•Pharmacy (19)

Target Audience
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Facility and Group Administrators

Setting of Care

•Hospitals (227)

•Psychiatric Facilities (1)

•Residential Facilities (19)

•Ambulatory Care (41)

•Outpatient Surgery (7)

•Patient Transport (5)

1 - 20 of 399

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STUDY

Insufficient communication about medication use at the interface between hospital and primary care.

Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

CONGRESSIONAL TESTIMONY

Oversight hearing on recent patient safety issues.

Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).

STUDY

Unscheduled returns to the emergency department: an outcome of medical errors?

Nuñez S, Hexdall A, Aguirre-Jaime A. Qual Saf Health Care. 2006;15:102-108.

STUDY

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

Kaissi A, Kralewski J, Dowd B, Heaton A. Health Care Manage Rev. 2007;32:12-21.

STUDY

Doctors' thinking about 'the system' as a threat to patient safety.

Waring JJ. Health (London). 2007;11:29-46.

STUDY

Preventable deaths in patients admitted from emergency department.

Lu T-C, Tsai C-L, Lee C-C, et al. Emerg Med J. 2006;23:452-455.

STUDY

Using system analysis to build a safety culture: improving the reliability of epidural analgesia.

Garnerin P, Huchet-Belouard A, Diby M, Clergue F. Acta Anaesthesiol Scand. 2006;50:1114-1119.

MULTI-USE WEBSITE

Maryland Patient Safety Center Emergency Department Collaborative.

Maryland Patient Safety Center.

STUDY

Costs and benefits of an early-alert surveillance system for hospital inpatients.

Marchetti A, Jacobs J, Young M, Martin J, Rossiter R. Curr Med Res Opin. 2007;23:9-16.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

COMMENTARY

Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."

Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Pediatrics. 2006;118:797-801.

REVIEW

Ethical and practical aspects of disclosing adverse events in the emergency department.

Stokes SL, Wu AW, Pronovost PJ. Emerg Med Clin North Am. 2006;24:703-714.

BOOK/REPORT

With Safety in Mind: Mental Health Services and Patient Safety.

Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.

STUDY

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

Miller MR, Pronovost P, Donithan M, et al. Am J Med Qual. 2005;20:239-252.

STUDY

Measurement of adverse events using "incidence flagged" diagnosis codes.

Jackson T, Duckett S, Shepheard J, Baxter K. J Health Serv Res Policy. 2006;11:21-26.

STUDY

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Pediatrics. 2005;116:603-608.

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