AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (55)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (74)

•Fatigue and Sleep Deprivation (34)

•Medication Safety (224)

•Medical Complications (58)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (98)

•Transfusion Complications (5)

•Psychological and Social Complications (25)

Origin/Sponsor

•Asia (19)

•Australia and New Zealand (14)

Resource Types

•Clinical Guideline (1)

•Journal Article (598)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (67)

•Press Release/Announcement (15)

•Special or Theme Issue (7)

•Tools/Toolkit (5)

•Web Resource (8)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (243)

•Active Errors (132)

•Latent Errors (43)

•Near Miss (22)

Approach to Improving Safety

•Quality Improvement Strategies (157)

•Legal and Policy Approaches (96)

•Error Reporting and Analysis (327)

•Communication Improvement (144)

•Human Factors Engineering (108)

•Teamwork (36)

•Specialization of Care (30)

•Logistical Approaches (64)

•Culture of Safety (56)

•Technologic Approaches (104)

•Education and Training (83)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (417)

•Psychiatric Facilities (3)

•Residential Facilities (11)

•Ambulatory Care (46)

•Outpatient Surgery (9)

•Patient Transport (10)

1 - 20 of 745

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STUDY

Enhancing medication use safety: benefits of learning from your peers.

Kazandjian VA, Ogunbo S, Wicker KG, Vaida AJ, Pipesh F. Qual Saf Health Care. 2009;18:331-335.

STUDY

Patient Safety Leadership WalkRounds.

Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Jt Comm J Qual Improv. 2003;29:16-26.

NEWSPAPER/MAGAZINE ARTICLE

The quality connection.

Solovy A. HHN Magazine (Hospitals & Health Networks). July 2005;79.

PENNSYLVANIA MEETING/CONFERENCE

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. June 13–14, 2013; Maggiano's, Philadelphia, PA.

STUDY

Reducing adverse drug events: lessons from a breakthrough series collaborative.

Leape LL, Kabcenell A, Gandhi TK, Carver P, Nolan TW, Berwick DM. Jt Comm J Qual Improv. 2000;26:321-331.

STUDY

Failure mode and effects analysis outputs: are they valid?

Shebl NA, Franklin BD, Barber N. BMC Health Serv Res. 2012;12:150.

STUDY

PCA safety data review after clinical decision support and smart pump technology implementation.

Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. J Patient Saf. 2013;9:103-109.

NEWSPAPER/MAGAZINE ARTICLE

Massachusetts hospitals launch patient apology program.

Gallegos A. American Medical News. May 21, 2012.

STUDY

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv. 2002;28:248-267, 209.

COMMENTARY

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.

STUDY

Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.

Armbruster DA, Alexander DB. Clin Chim Acta. 2006;373:37-43.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

STUDY

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

STUDY

Cost-effective enhancement of claims data to improve comparisons of patient safety.

Jordan HS, Pine M, Elixhauser A, et al. J Patient Saf. 2007;3:82-90.

STUDY

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

Spector WD, Mutter R, Owens P, Limcangco R. Med Care. 2012;50:863-869.

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