AHRQ Patient Safety Network

The Collection > Facility and Group Administrators

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (18)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (57)

•Fatigue and Sleep Deprivation (22)

•Medication Safety (144)

•Medical Complications (35)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (37)

•Transfusion Complications (2)

•Psychological and Social Complications (14)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (8)

Resource Types

•Clinical Guideline (1)

•Journal Article (337)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (47)

•Special or Theme Issue (5)

•Tools/Toolkit (8)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (92)

•Active Errors (37)

•Latent Errors (25)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (123)

•Legal and Policy Approaches (45)

•Error Reporting and Analysis (156)

•Communication Improvement (99)

•Human Factors Engineering (32)

•Teamwork (30)

•Specialization of Care (29)

•Logistical Approaches (55)

•Culture of Safety (74)

•Technologic Approaches (99)

•Education and Training (62)

Clinical Areas

•Medicine (260)

•Nursing (33)

•Pharmacy (28)

Target Audience
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Facility and Group Administrators

Setting of Care

•Hospitals (239)

•Psychiatric Facilities (1)

•Residential Facilities (23)

•Ambulatory Care (62)

•Outpatient Surgery (7)

•Patient Transport (6)

1 - 20 of 438

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COMMENTARY

Putting power into patient safety: interventions.

Astion M. Laboratory Errors & Patient Safety. May-June 2005;1:5-8.

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

COMMENTARY

Putting power into patient safety interventions. Part two: 99% is not good enough.

Astion M. Laboratory Errors & Patient Safety. July-August 2005;2:1-4.

COMMENTARY classic

Five years after 'To Err is Human': what have we learned?

Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

Patient safety concerns arising from test results that return after hospital discharge.

Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

MEASUREMENT TOOL/INDICATOR

The Physician Practice Patient Safety Assessment.

Medical Group Management Association Center for Research, Health Research and Educational Trust, Institute for Safe Medication Practices. 2005.

STUDY

The safety of hospital stroke care.

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

STUDY

The safety culture in a children's hospital.

Grant MJC, Donaldson AE, Larsen GY. J Nurs Care Qual. 2006;21:223-229.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

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

REVIEW

Safety in the academic medical center: transforming challenges into ingredients for improvement.

Blumenthal D, Ferris TG. Acad Med. 2006;81:817-822.

STUDY

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

Tsai JJ, Yeun JY, Kumar VA, Don BR. Am J Kidney Dis. 2005;46:820-829.

COMMENTARY

Unintended errors with EHR-based result management: a case series.

Yackel TR, Embi PJ. J Am Med Inform Assoc. 2010;17:104-107.

NEWSLETTER/JOURNAL

Patient Safety Link.

Joint Commission International Center for Patient Safety.

STUDY

Outpatient adverse drug events identified by screening electronic health records.

Gandhi TK, Seger AC, Overhage JM, et al. J Patient Saf. 2010;6;91-96.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

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