AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (46)

•Diagnostic Errors (68)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (85)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (260)

•Medical Complications (62)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (119)

•Transfusion Complications (6)

•Psychological and Social Complications (28)

Origin/Sponsor

•Asia (25)

•Australia and New Zealand (25)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (690)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (14)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (300)

•Active Errors (153)

•Latent Errors (49)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (185)

•Legal and Policy Approaches (99)

•Error Reporting and Analysis (380)

•Communication Improvement (151)

•Human Factors Engineering (119)

•Teamwork (38)

•Specialization of Care (33)

•Logistical Approaches (70)

•Culture of Safety (64)

•Technologic Approaches (119)

•Education and Training (93)

Clinical Areas

•Allied Health Services (3)

•Medicine (567)

•Nursing (39)

•Pharmacy (84)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (466)

•Psychiatric Facilities (2)

•Residential Facilities (10)

•Ambulatory Care (50)

•Outpatient Surgery (12)

•Patient Transport (7)

1 - 20 of 845

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STUDY

Bar-code verification: reducing but not eliminating medication errors.

Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

STUDY

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

STUDY

Multiple patient safety events within a single hospitalization: a national profile in US hospitals.

Yu H, Greenberg MD, Haviland AM, Farley DO. Am J Med Qual. 2012;27:472-479.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

NEWSPAPER/MAGAZINE ARTICLE

Under-mined.

Greene J. Hosp Health Netw. December 2006.

STUDY

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

Etchegaray JM, Thomas EJ. BMJ Qual Saf. 2012;21:490-498.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

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

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

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

Morris DS, Schweickert W, Holena D, et al. Resuscitation. 2012;83:1434-1437.

STUDY

The costs of adverse drug events in community hospitals.

Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

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