AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (16)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (53)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (110)

•Medical Complications (31)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (34)

•Transfusion Complications (3)

•Psychological and Social Complications (9)

Origin/Sponsor

•Australia and New Zealand (21)

•North America (285)

Resource Types

•Book/Report (18)

•Journal Article (300)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (38)

•Press Release/Announcement (1)

•Special or Theme Issue (3)

•Tools/Toolkit (11)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (90)

•Active Errors (31)

•Latent Errors (30)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (123)

•Legal and Policy Approaches (42)

•Error Reporting and Analysis (163)

•Communication Improvement (75)

•Human Factors Engineering (29)

•Teamwork (30)

•Specialization of Care (30)

•Logistical Approaches (39)

•Culture of Safety (76)

•Technologic Approaches (82)

•Education and Training (58)

Clinical Areas

•Allied Health Services (1)

•Complementary and Alternative Medicine (1)

•Medicine (222)

•Nursing (22)

•Pharmacy (16)

Target Audience
< All

Facility and Group Administrators

Setting of Care

•Hospitals (211)

•Psychiatric Facilities (2)

•Residential Facilities (20)

•Ambulatory Care (38)

•Outpatient Surgery (8)

•Patient Transport (4)

1 - 20 of 385

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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.

SPECIAL OR THEME ISSUE

Patient Safety Papers.

Baker GR, ed. Healthc Q. 2005;8:1-156.

STUDY

Medicare payment for selected adverse events: building the business case for investing in patient safety.

Zhan C, Friedman B, Mosso A, Pronovost P. Health Aff (Millwood). 2006;25:1386-1393.

STUDY

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators.

Coffey RM, Andrews RM, Moy E. Med Care. 2005;43(suppl 3):I48-I57.

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

STUDY

The safety culture in a children's hospital.

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

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

BOOK/REPORT

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

Washington, DC: United States Government Accountability Office; 2005. Report No. GAO-06-117.

REVIEW

Epidemiology of medication-related adverse events in nursing homes.

Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.

STUDY

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit.

Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-861.

STUDY

Barriers to nurses' reporting of medication administration errors in Taiwan.

Chiang HY, Pepper GA. J Nurs Scholarsh. 2006;38:392-399.

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.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.

Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.

TOOLKIT

Manchester Patient Safety Framework (MaPSaF).

Manchester, UK: University of Manchester; 2006.

BOOK/REPORT

Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report.

Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0071.

STUDY

Work-hour restrictions as an ethical dilemma for residents.

Carpenter RO, Austin MT, Tarpley JL, Griffin MR, Lomis KD. Amer J Surg. 2006;191:527-532.

MEETING/CONFERENCE PROCEEDINGS

Making the Health Care System Safer Through Implementation and Innovation.

Agency for Healthcare Research and Quality. Kaisernetwork.org Web site. June 8, 2005.

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.

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