AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (12)

•Diagnostic Errors (21)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (75)

•Fatigue and Sleep Deprivation (31)

•Medication Safety (172)

•Medical Complications (39)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (46)

•Transfusion Complications (3)

•Psychological and Social Complications (15)

Origin/Sponsor

•Australia and New Zealand (22)

•North America (436)

Resource Types

•Audiovisual (2)

•Book/Report (25)

•Clinical Guideline (1)

•Journal Article (441)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•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 (126)

•Active Errors (49)

•Latent Errors (36)

•Near Miss (14)

Approach to Improving Safety

•Quality Improvement Strategies (155)

•Legal and Policy Approaches (56)

•Error Reporting and Analysis (195)

•Communication Improvement (123)

•Human Factors Engineering (46)

•Teamwork (37)

•Specialization of Care (36)

•Logistical Approaches (64)

•Culture of Safety (91)

•Technologic Approaches (126)

•Education and Training (79)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

•Medicine (333)

•Nursing (37)

•Pharmacy (31)

Target Audience
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Facility and Group Administrators

Setting of Care

•Hospitals (297)

•Psychiatric Facilities (1)

•Residential Facilities (28)

•Ambulatory Care (77)

•Outpatient Surgery (10)

•Patient Transport (6)

1 - 20 of 559

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STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

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.

STUDY

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. Crit Care Med. 2013;41:389-398.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

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

STUDY

An observational study of changes to long-term medication after admission to an intensive care unit.

Campbell AJ, Bloomfield R, Noble DW. Anaesthesia. 2006;61:1087-1092.

STUDY

Implementing and validating a comprehensive unit-based safety program.

Pronovost P, Weast B, Rosenstein B. J Patient Saf. 2005;1:33-40.

STUDY

Development of the ICU safety reporting system.

Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1:23-32.

STUDY

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Crit Care Med. 2006;34:1016-1024.

REVIEW

Failure mode and effects analysis application to critical care medicine.

Duwe B, Fuchs BD, Hansen-Flaschen J. Crit Care Clin. 2005;21:21-30, vii.

COMMENTARY

Eliminating preventable death at Ascension Health.

Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Jt Comm J Qual Patient Saf. 2007;33:145-154.

NEWSPAPER/MAGAZINE ARTICLE

Intensivists: an Rx for the ICU?

Meyers S. Trustee. March 2006;59:29-30.

STUDY

classic

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Personalised performance feedback reduces narcotic prescription errors in a NICU.

Sullivan KM, Suh S, Monk H, Chuo J. BMJ Qual Saf. 2013;22:256-262.

STUDY

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units.

Parshuram CS, Kirpalani H, Mehta S, Granton J, Cook D, for the Canadian Critical Care Trials Group. Crit Care Med. 2006;34:1674-78.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey.

de Bie J, Cuperus-Bosma JM, van der Jagt MAB, Gevers JKM, van der Wal G. Int J Nurs Stud. 2005;42:637-648.

STUDY

Retrospective analysis of medication incidents reported using an on-line reporting system.

Ashcroft DM, Cooke J. Pharm World Sci. 2006;28:359-65.

STUDY

classic

Outcomes of care by hospitalists, general internists, and family physicians.

Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. N Engl J Med. 2007;357:2589-2600.

STUDY

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms.

Hume AL, Quilliam BJ, Goldman R, Eaton C, Lapane KL. BMJ Qual Saf. 2011;20:875-884.

STUDY

Automated surveillance for adverse drug events at a community hospital and an academic medical center.

Kilbridge PM, Campbell UC, Cozart HB, Mojarrad MG. J Am Med Inform Assoc. 2006;13:372-377.

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