AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (62)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (79)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (242)

•Medical Complications (60)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (110)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (26)

•Australia and New Zealand (22)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (652)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (12)

•Special or Theme Issue (9)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (270)

•Active Errors (142)

•Latent Errors (43)

•Near Miss (23)

Approach to Improving Safety

•Quality Improvement Strategies (176)

•Legal and Policy Approaches (97)

•Error Reporting and Analysis (357)

•Communication Improvement (147)

•Human Factors Engineering (118)

•Teamwork (39)

•Specialization of Care (33)

•Logistical Approaches (70)

•Culture of Safety (69)

•Technologic Approaches (111)

•Education and Training (89)

Clinical Areas

•Allied Health Services (1)

•Medicine (532)

•Nursing (40)

•Pharmacy (79)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (447)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (49)

•Outpatient Surgery (11)

•Patient Transport (7)

1 - 20 of 806

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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.

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.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Under-mined.

Greene J. Hosp Health Netw. December 2006.

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.

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.

STUDY

Adverse-event-reporting practices by US hospitals: results of a national survey.

Farley DO, Haviland A, Champagne S, et al. Qual Saf Health Care. 2008;17:416-423.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

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.

FACT SHEET/FAQS

10 Tips to Help Promote Patient Safety.

Chicago, IL: American Society for Healthcare Risk Management; 2013.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

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

STUDY

Costs and benefits of an early-alert surveillance system for hospital inpatients.

Marchetti A, Jacobs J, Young M, Martin J, Rossiter R. Curr Med Res Opin. 2007;23:9-16.

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.

STUDY

Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration.

Taylor JA, Gerwin D, Morlock L, Miller MR. Inj Prev. 2011;17:388-393.

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.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

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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