AHRQ Patient Safety Network

The Collection > Quality and Safety Professionals

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Safety Target

•Device-related Complications (111)

•Diagnostic Errors (115)

•Identification Errors (88)

•Discontinuities, Gaps, and Hand-Off Problems (278)

•Fatigue and Sleep Deprivation (51)

•Medication Safety (743)

•Medical Complications (304)

•Nonsurgical Procedural Complications (79)

•Surgical Complications (326)

•Transfusion Complications (13)

•Psychological and Social Complications (71)

Origin/Sponsor

•Africa (2)

•Asia (44)

•Australia and New Zealand (86)

•Central and South America (6)

•Europe (380)

•North America (1866)

Resource Types

•Audiovisual (8)

•Award (5)

•Book/Report (75)

•Clinical Guideline (3)

•Journal Article (2032)

•Legislation/Regulation (31)

•Meeting/Conference (11)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (133)

•Press Release/Announcement (15)

•Special or Theme Issue (28)

•Tools/Toolkit (21)

•Web Resource (42)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (667)

•Active Errors (433)

•Latent Errors (153)

•Near Miss (51)

Approach to Improving Safety

•Quality Improvement Strategies (611)

•Legal and Policy Approaches (115)

•Error Reporting and Analysis (704)

•Communication Improvement (568)

•Human Factors Engineering (382)

•Teamwork (243)

•Specialization of Care (178)

•Logistical Approaches (176)

•Culture of Safety (343)

•Technologic Approaches (436)

•Education and Training (468)

Clinical Areas

•Allied Health Services (8)

•Complementary and Alternative Medicine (1)

Target Audience
< All

Quality and Safety Professionals

Setting of Care

•Hospitals (1625)

•Psychiatric Facilities (6)

•Residential Facilities (37)

•Ambulatory Care (182)

•Outpatient Surgery (22)

•Patient Transport (18)

1 - 20 of 2413

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STUDY

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. Int J Med Inform. 2009;78(suppl 1): S69-S76.

NEWSPAPER/MAGAZINE ARTICLE

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital.

Karapinar-Çarkit F, Borgsteede SD, Zoer J, Smit HJ, Egberts ACG, van den Bemt PMLA. Ann Pharmacother. 2009;43:1001-1010.

STUDY

Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.

Hilmas E, Peoples JD. JPEN J Parenter Enteral Nutr. 2012;36(suppl 2):32S-35S.

COMMENTARY

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

Melnyk BM. Nurs Adm Q. 2012;36:127-135.

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

STUDY

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010;126:14-21.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.

Rask K, Culler S, Scott T, et al. J Hosp Med. 2007;2:212-218.

STUDY

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

Mohta N, Vaishnava P, Liang C, et al. BMJ Qual Saf. 2012;21:885-890.

MULTI-USE WEBSITE

Aware in Care.

Miami, FL: National Parkinson Foundation; October 2012.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

STUDY

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting.

Makowsky MJ, Schindel TJ, Rosenthal M, Campbell K, Tsuyuki RT, Madill HM. J Interprof Care. 2009;23:169-84.

STUDY

Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.

Clare CA, Afzal O, Knapp K, Viola D. J Patient Saf. 2013;9:68-74.

BOOK/REPORT

The Patient Safety Leadership WalkRounds Guide.

Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006.

COMMENTARY

Mitigating error vulnerability at the transition of care through the use of health IT applications.

Cortelyou-Ward K, Swain A, Yeung T. J Med Syst. 2012;36:3825-3831.

COMMENTARY

Medication reconciliation in a community, nonteaching hospital.

Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.

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