AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (63)

•Diagnostic Errors (3)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (5)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (40)

•Medical Complications (10)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (13)

•Psychological and Social Complications (2)

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•Australia and New Zealand (3)

•North America (140)

Resource Types

•Audiovisual (3)

•Book/Report (11)

•Journal Article (115)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newspaper/Magazine Article (28)

•Press Release/Announcement (3)

•Special or Theme Issue (6)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (24)

•Active Errors (24)

•Latent Errors (31)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (26)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (32)

•Communication Improvement (9)

•Human Factors Engineering (137)

•Teamwork (5)

•Specialization of Care (4)

•Logistical Approaches (12)

•Culture of Safety (15)

•Technologic Approaches (48)

•Education and Training (23)

Clinical Areas

•Allied Health Services (2)

•Medicine (107)

•Nursing (10)

•Pharmacy (4)

Target Audience
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Engineers

Setting of Care

•Hospitals (98)

•Residential Facilities (2)

•Ambulatory Care (11)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 176

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NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

ORGANIZATIONAL POLICY/GUIDELINES

Medical device alarm safety in hospitals.

Sentinel Event Alert. April 8, 2013;(50):1-3.

STUDY

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.

ORGANIZATIONAL POLICY/GUIDELINES

Radiation risks of diagnostic imaging.

Sentinel Event Alert #47. August 24, 2011.

REVIEW

Enteral feeding misconnections: an update.

Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.

REVIEW

Tubing misconnections: normalization of deviance.

Simmons D, Symes L, Guenter P, Graves K. Nutr Clin Pract. 2011;26:286-293.

COMMENTARY

Enteral feeding misconnections: a consortium position statement.

Guenter P, Hicks RW, Simmons D, et al. Jt Comm J Qual Patient Saf. 2008;34:285-292.

NEWSPAPER/MAGAZINE ARTICLE

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

COMMENTARY

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.

STUDY

Management of anesthesia equipment failure: a simulation-based resident skill assessment.

Waldrop WB, Murray DJ, Boulet JR, Kras JF. Anesth Analg. 2009;109:426-433.

NEWSPAPER/MAGAZINE ARTICLE

ALERT: reports of severe harm after intravenous administration of breast milk to infants.

ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.

COMMENTARY

MRI suites: safety outside the bore.

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

COMMENTARY

Perfusion safety: new initiatives and enduring principles.

Kurusz M. Perfusion. 2011;26(suppl 1):6-14.

PRESS RELEASE/ANNOUNCEMENT

Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.

Rockville, MD: US Food and Drug Administration; November 9, 2010.

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.

STUDY

An engineered solution to the maladministration of spinal injections.

Lawton R, Gardner P, Green B, et al. Qual Saf Health Care. 2009;18:492-495.

STUDY

Effect of computerized physician order entry on radiologic examination order indication quality.

Schneider E, Franz W, Spitznagel R, Bascom DA, Obuchowski NA. Arch Intern Med. 2011;171:1036-1038.

NEWSPAPER/MAGAZINE ARTICLE

Doctors see flaw in device recalls.

Kerber R. The Boston Globe. June 23, 2005;Business section:E1.

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