AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (96)

•Diagnostic Errors (99)

•Identification Errors (65)

•Discontinuities, Gaps, and Hand-Off Problems (200)

•Fatigue and Sleep Deprivation (23)

•Medication Safety (566)

•Medical Complications (258)

•Nonsurgical Procedural Complications (57)

•Surgical Complications (265)

•Transfusion Complications (11)

•Psychological and Social Complications (38)

Origin/Sponsor

•Australia and New Zealand (134)

•Central and South America (8)

•Europe (347)

•North America (1185)

Resource Types

•Audiovisual (5)

•Book/Report (47)

•Clinical Guideline (3)

•Journal Article (1507)

•Legislation/Regulation (17)

•Meeting/Conference (9)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (62)

•Press Release/Announcement (13)

•Special or Theme Issue (14)

•Tools/Toolkit (12)

•Web Resource (31)

Error Types

•Epidemiology of Errors and Adverse Events (749)

•Active Errors (370)

•Latent Errors (92)

•Near Miss (50)

Approach to Improving Safety

•Quality Improvement Strategies (428)

•Legal and Policy Approaches (75)

•Error Reporting and Analysis (565)

•Communication Improvement (408)

•Human Factors Engineering (271)

•Teamwork (165)

•Specialization of Care (151)

•Logistical Approaches (98)

•Culture of Safety (184)

•Technologic Approaches (299)

•Education and Training (318)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

•Dentistry (3)

•Medicine (1348)

•Nursing (147)

•Pharmacy (174)

Target Audience
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Quality and Safety Professionals

Setting of Care

•Hospitals (1213)

•Psychiatric Facilities (6)

•Residential Facilities (27)

•Ambulatory Care (137)

•Outpatient Surgery (16)

•Patient Transport (20)

1 - 20 of 1731

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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.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis.

Bhonagiri D, Pilcher DV, Bailey MJ. Med J Aust. 2011;194:287-292.

STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

STUDY

Prevalence of adverse events in pediatric intensive care units in the United States.

Agarwal S, Classen D, Larsen G, et al. Pediatr Crit Care Med. 2010;11:568-578.

STUDY

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.

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.

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

Iatrogenic events contributing to ICU admission: a prospective study.

Mercier E, Giraudeau B, Giniès G, Perrotin D, Dequin PF. Intensive Care Med. 2010;36:1033-1037.

STUDY

Barriers to adverse event and error reporting in anesthesia.

Heard GC, Sanderson PM, Thomas RD. Anesth Analg. 2012;114:604-614.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.

REVIEW

Medical error and decision making: learning from the past and present in intensive care.

Bucknall TK. Aust Crit Care. 2010;23:150-156.

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