AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (19)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (29)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (89)

•Medical Complications (69)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (53)

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•Psychological and Social Complications (13)

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•Journal Article (291)

•Legislation/Regulation (22)

•Meeting/Conference (13)

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Error Types

•Epidemiology of Errors and Adverse Events (76)

•Active Errors (32)

•Latent Errors (40)

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Approach to Improving Safety

•Quality Improvement Strategies (158)

•Legal and Policy Approaches (305)

•Error Reporting and Analysis (254)

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•Education and Training (86)

Clinical Areas

•Allied Health Services (1)

•Medicine (235)

•Nursing (11)

•Pharmacy (32)

Target Audience
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Policy Makers

Setting of Care

•Hospitals (231)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (42)

•Outpatient Surgery (10)

•Patient Transport (1)

1 - 20 of 560

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COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

MULTI-USE WEBSITE

Safe Surgery 2015.

Harvard School of Public Health.

STUDY

The $17.1 billion problem: the annual cost of measurable medical errors.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

STUDY

Should all duty hours be the same? Results of a national survey of surgical trainees.

Moalem J, Salzman P, Ruan DT, et al. J Am Coll Surg. 2009;209:47-54.

COMMENTARY

The Perruche case and the issue of compensation for the consequences of medical error.

Costich JF. Health Policy. 2006;78:8-16.

COMMENTARY

The partnership with patients: a call to action for leaders.

Denham CR. J Patient Saf. 2011;7:113-121.

NEWSPAPER/MAGAZINE ARTICLE

In a crisis, do-not-revive requests don't always work.

Parker L. USA Today. December 19, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

BOOK/REPORT

A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.

Stremikis K, Schoen C, Fryer AK. 2011;6:1492.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.

STUDY

No harm found when nurse anesthetists work without supervision by physicians.

Dulisse B, Cromwell J. Health Aff (Millwood). 2010;29:1469-1475.

BOOK/REPORT classic

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2011.

Oakbrook Terrace, IL: The Joint Commission; September 2011.

COMMENTARY

Setting priorities for patient safety: ethics, accountability, and public engagement.

Pronovost PJ, Faden RR. JAMA. 2009;302:890-891.

STUDY

Sharing lessons learned to prevent incorrect surgery.

Neily J, Mills PD, Paull DE, et al. Am Surg. 2012;78:1276-1280.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

STUDY

Relationship between occurrence of surgical complications and hospital finances.

Eappen S, Lane BH, Rosenberg B, et al. JAMA. 2013;309:1599-1606.

ORGANIZATIONAL POLICY/GUIDELINES

Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.

Goodman KW, Berner ES, Dente MA, et al; AMIA Board of Directors. J Am Med Inform Assoc. 2011;18:77-81.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

COMMENTARY

Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.

Bovbjerg RR, Tancredi LR. J Law Med Ethics. 2005;33:478-500.

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