AHRQ Patient Safety Network

The Collection > Facility and Group Administrators

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Safety Target

•Device-related Complications (10)

•Diagnostic Errors (18)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (164)

•Medical Complications (39)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (41)

•Transfusion Complications (3)

•Psychological and Social Complications (14)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (19)

Resource Types

•Clinical Guideline (1)

•Journal Article (405)

•Legislation/Regulation (7)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (52)

•Press Release/Announcement (1)

•Special or Theme Issue (5)

•Tools/Toolkit (10)

•Web Resource (12)

Error Types

•Epidemiology of Errors and Adverse Events (111)

•Active Errors (43)

•Latent Errors (32)

•Near Miss (13)

Approach to Improving Safety

•Quality Improvement Strategies (143)

•Legal and Policy Approaches (61)

•Error Reporting and Analysis (185)

•Communication Improvement (117)

•Human Factors Engineering (44)

•Teamwork (36)

•Specialization of Care (34)

•Logistical Approaches (63)

•Culture of Safety (90)

•Technologic Approaches (116)

•Education and Training (78)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

•Medicine (304)

•Nursing (38)

•Pharmacy (30)

Target Audience
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Facility and Group Administrators

Setting of Care

•Hospitals (273)

•Residential Facilities (27)

•Ambulatory Care (74)

•Outpatient Surgery (10)

•Patient Transport (4)

1 - 20 of 527

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BOOK/REPORT

Framework for a High Performance Health System for the United States.

The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.

STUDY

Errors prevented by and associated with bar-code medication administration systems.

Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:293-301.

STUDY

Improving the bar-coded medication administration system at the Department of Veterans Affairs.

Mills PD, Neily J, Mims E, Burkhardt ME, Bagian J. Am J Health Syst Pharm. 2006;63:1442-1447.

SPECIAL OR THEME ISSUE

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

Amer Surg. 2006;72:985-1149

COMMENTARY classic

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

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

NEWSPAPER/MAGAZINE ARTICLE

Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.

Carbasho T. Pittsburgh Business Times. April 25, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Surgical errors: new products, protocols help slash the risks.

Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.

COMMENTARY classic

Accidental deaths, saved lives, and improved quality.

Brennan TA, Gawande A, Thomas E, Studdert D. N Engl J Med. 2005;353:1405-1409.

BOOK/REPORT

Safety First: One Year On.

London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634093.

STUDY

Medication safety infrastructure in critical-access hospitals in Florida.

Winterstein AG, Hartzema AG, Johns TE, et al. Am J Health Syst Pharm. 2006;63:442-450.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

BOOK/REPORT

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

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

STUDY

Medication errors in paediatric outpatients.

Kaushal R, Goldmann DA, Keohane CA, et al. Qual Saf Health Care. 2010;19:e30.

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.

MULTI-USE WEBSITE

Quality & Safety Research Group.

Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.

COMMENTARY

Findings of the first consensus conference on medical emergency teams.

Devita MA, Bellomo R, Hillman K, et al. Crit Care Med. 2006;34;2463-2478.

REVIEW

Quality in cancer diagnosis.

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

STUDY

Residents report on adverse events and their causes.

Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Arch Intern Med. 2005;165:2607-2613.

COMMENTARY

Collegiality vs. Competence

Sagin T. AHRQ WebM&M [serial online]. March 2006.

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