AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (62)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (44)

•Medication Safety (238)

•Medical Complications (59)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (120)

•Transfusion Complications (5)

•Psychological and Social Complications (26)

Origin/Sponsor

•Australia and New Zealand (24)

•Central and South America (1)

•Europe (108)

•North America (635)

Resource Types

•Audiovisual (8)

•Book/Report (26)

•Clinical Guideline (1)

•Journal Article (662)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (16)

•Special or Theme Issue (8)

•Tools/Toolkit (6)

•Web Resource (7)

Error Types

•Epidemiology of Errors and Adverse Events (264)

•Active Errors (146)

•Latent Errors (46)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (179)

•Legal and Policy Approaches (104)

•Error Reporting and Analysis (361)

•Communication Improvement (157)

•Human Factors Engineering (120)

•Teamwork (43)

•Specialization of Care (31)

•Logistical Approaches (72)

•Culture of Safety (64)

•Technologic Approaches (113)

•Education and Training (98)

Clinical Areas

•Allied Health Services (2)

•Dentistry (1)

•Medicine (545)

•Nursing (40)

•Pharmacy (76)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (440)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (49)

•Outpatient Surgery (11)

•Patient Transport (9)

1 - 20 of 819

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SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

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

classic

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Crit Care Med. 2006;34:1016-1024.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

REVIEW

Inpatient suicide: preventing a common sentinel event.

Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2010;35:124-133.

STUDY

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Real time patient safety audits: improving safety every day.

Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.

STUDY

classic

Fall prevention in acute care hospitals: a randomized trial.

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

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.

COMMENTARY

ISMP medication error report analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

Patient safety in the ED.

Scalise D, Lazar C. Hosp Health Netw. May 2006:80:5,48,2.

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