AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (39)

•Diagnostic Errors (49)

•Identification Errors (27)

•Discontinuities, Gaps, and Hand-Off Problems (58)

•Fatigue and Sleep Deprivation (30)

•Medication Safety (184)

•Medical Complications (36)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (75)

•Transfusion Complications (5)

•Psychological and Social Complications (18)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (5)

Resource Types

•Journal Article (478)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (64)

•Press Release/Announcement (9)

•Special or Theme Issue (5)

•Tools/Toolkit (5)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (189)

•Active Errors (112)

•Latent Errors (31)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (127)

•Legal and Policy Approaches (80)

•Error Reporting and Analysis (266)

•Communication Improvement (114)

•Human Factors Engineering (105)

•Teamwork (27)

•Specialization of Care (27)

•Logistical Approaches (58)

•Culture of Safety (50)

•Technologic Approaches (88)

•Education and Training (70)

Clinical Areas

•Allied Health Services (1)

•Medicine (401)

•Nursing (29)

•Pharmacy (67)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (314)

•Psychiatric Facilities (1)

•Residential Facilities (9)

•Ambulatory Care (37)

•Outpatient Surgery (8)

•Patient Transport (7)

1 - 20 of 607

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NEWSPAPER/MAGAZINE ARTICLE

Ounce of prevention: to reduce errors, hospitals prescribe innovative designs.

Naik G. The Wall Street Journal. May 8, 2006:A1.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing adverse events caused by emergency electrical power system failures.

Sentinel Event Alert. September 6, 2006;(37):1-3.

SPECIAL OR THEME ISSUE

Safety by design.

Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.

COMMENTARY

Engineering risk analysis of a hospital oxygen supply system.

Deleris LA, Yeo GL, Seiver A, Pate-Cornell ME. Med Decis Making. 2006;26:162-172.

STUDY

Usability study of two common defibrillators reveals hazards.

Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Ann Emerg Med. 2007;50:424-432.

COMMENTARY

MRI suites: safety outside the bore.

Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.

STUDY

Rate of occult specimen provenance complications in routine clinical practice.

Pfeifer JD, Liu J. Am J Clin Pathol. 2013;139:93-100.

STUDY

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

Hundt AS, Adams JA, Schmid JA, et al. Int J Med Inform. 2013;82:25-38.

COMMENTARY

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

COMMENTARY

Detection of patient risk by nurses: a theoretical framework.

Despins LA, Scott-Cawiezell J, Rouder JN. J Adv Nurs. 2010;66:465-474.

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.

COMMENTARY

Risk, society and system failure.

Scalliet P. Radiother Oncol. 2006;80:275-281.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

STUDY

EMS helicopter crashes: what influences fatal outcome?

Baker SP, Grabowski JG, Dodd RS, Shanahan DF, Lamb MW, Li GH. Ann Emerg Med. 2006;47:351-356.

STUDY

Using the ISMP Medication Safety Self-Assessment to improve medication use processes.

Lesar T, Mattis A, Anderson E, et al. Jt Comm J Qual Saf. 2003;29:211-226.

STUDY

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ford EC, Smith K, Harris K, Terezakis S. Med Phys. 2012;39:6968-6971.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

REVIEW

Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.

Weinger MB, Englund CE. Anesthesiology. 1990;73:995-1021.

COMMENTARY

Impatient Inpatient Dosing

White RH. AHRQ WebM&M [serial online]. July/August 2005.

NEWSPAPER/MAGAZINE ARTICLE

Pharmaceutical industry and medical device companies: part of the solution?

ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.

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