AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (55)

•Identification Errors (28)

•Discontinuities, Gaps, and Hand-Off Problems (88)

•Fatigue and Sleep Deprivation (36)

•Medication Safety (189)

•Medical Complications (56)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (127)

•Transfusion Complications (5)

•Psychological and Social Complications (21)

Origin/Sponsor

•Australia and New Zealand (22)

•Central and South America (1)

•Europe (115)

•North America (443)

Resource Types

•Audiovisual (2)

•Book/Report (17)

•Journal Article (554)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•Newspaper/Magazine Article (38)

•Press Release/Announcement (6)

•Special or Theme Issue (3)

•Tools/Toolkit (2)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (300)

•Active Errors (109)

•Latent Errors (52)

•Near Miss (19)

Approach to Improving Safety

•Quality Improvement Strategies (133)

•Legal and Policy Approaches (57)

•Error Reporting and Analysis (305)

•Communication Improvement (115)

•Human Factors Engineering (81)

•Teamwork (33)

•Specialization of Care (29)

•Logistical Approaches (58)

•Culture of Safety (45)

•Technologic Approaches (88)

•Education and Training (65)

Clinical Areas

•Allied Health Services (3)

•Medicine (481)

•Nursing (27)

•Pharmacy (53)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (401)

•Psychiatric Facilities (3)

•Residential Facilities (9)

•Ambulatory Care (41)

•Outpatient Surgery (11)

•Patient Transport (9)

1 - 20 of 633

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STUDY

Assessment of adverse drug events among patients in a tertiary care medical center.

Johnston PE, France DJ, Byrne DW, et al. Am J Health Syst Pharm. 2006;63:2218-2227.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Potentially unintended discontinuation of long-term medication use after elective surgical procedures.

Bell CM, Bajcar J, Bierman AS, et al. Arch Intern Med. 2006;166:2525-2531.

STUDY

Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.

Rampersaud YR, Moro ER, Neary MA, et al. Spine. 2006;31:1503-1510.

STUDY

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84:1602-1609.

STUDY

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups.

Kernaghan D, Penney GC. Qual Saf Health Care. 2006;15:359-362.

COMMENTARY

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

Manuel BM, Greenwald LM. Bull Am Coll Surg. March 2007;92:27-30.

STUDY

Impact of intensive care unit discharge time on patient outcome.

Priestap FA, Martin CM. Crit Care Med. 2006;34:2946-2951.

STUDY

Transfers of patient care between house staff on internal medicine wards: a national survey.

Horwitz LI, Krumholz HM, Green ML, Huot SJ. Arch Intern Med. 2006;166:1173-1177.

CONGRESSIONAL TESTIMONY

Oversight hearing on recent patient safety issues.

Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).

REVIEW

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

classic

Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.

Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

The effect of a rapid response team on major clinical outcome measures in a community hospital.

Dacey MJ, Mirza ER, Wilcox V, et al. Crit Care Med. 2007;35:2076-2082.

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