AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (11)

•Diagnostic Errors (16)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (23)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (76)

•Medical Complications (63)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (44)

•Transfusion Complications (2)

•Psychological and Social Complications (12)

Origin/Sponsor

•Africa (1)

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Resource Types

•Journal Article (271)

•Legislation/Regulation (21)

•Meeting/Conference (8)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (70)

•Press Release/Announcement (2)

•Special or Theme Issue (11)

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Error Types

•Epidemiology of Errors and Adverse Events (68)

•Active Errors (28)

•Latent Errors (35)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (132)

•Legal and Policy Approaches (283)

•Error Reporting and Analysis (221)

•Communication Improvement (62)

•Human Factors Engineering (28)

•Teamwork (20)

•Specialization of Care (9)

•Logistical Approaches (36)

•Culture of Safety (74)

•Technologic Approaches (72)

•Education and Training (73)

Clinical Areas

•Medicine (214)

•Nursing (11)

•Pharmacy (29)

Target Audience
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Policy Makers

Setting of Care

•Hospitals (236)

•Psychiatric Facilities (4)

•Residential Facilities (11)

•Ambulatory Care (38)

•Outpatient Surgery (12)

•Patient Transport (1)

1 - 20 of 498

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STUDY

Nurse staffing and inpatient hospital mortality.

Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. N Engl J Med. 2011;364:1037-1045.

BOOK/REPORT

Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.

Casey MM, Moscovice I, Davidson G. Upper Midwest Rural Health Research Center; December 2005.

NEWSPAPER/MAGAZINE ARTICLE

State: nurse error caused death.

Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.

BOOK/REPORT

Addressing the quality and safety gap—parts I-II.

Princeton, NJ: Robert Wood Johnson Foundation; July 2009.

COMMENTARY

The criminalization of mistakes in nursing.

Philipsen NC. J Nurse Pract. 2011;7:719-726.

PENNSYLVANIA LEGISLATION

Prohibition of Excessive Overtime for Nurses Act.

The General Assembly of Pennsylvania. HB957 (2005).

STUDY

Putting the 'patient' in patient safety: a qualitative study of consumer experiences.

Rathert C, Brandt J, Williams ES. Health Expect. 2012;15:327-336.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.

NEWSPAPER/MAGAZINE ARTICLE

How to stay on the right side of the infection control code.

Harrison S. Nurs Stand. June 1-7, 2005;19:14-16.

BOOK/REPORT

Framework for a High Performance Health System for the United States.

The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.

COMMENTARY

Residents' duty hours—toward an empirical narrative.

Rosenbaum L, Lamas D. N Engl J Med. 2012;367:2044-2049.

COMMENTARY

Exploring the role of patients in promoting safety: policy to practice.

Holme A. Br J Nurs. 2009;18:1392-1395.

COMMENTARY classic

Five years after 'To Err is Human': what have we learned?

Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals lagging in PSO contracts.

Clarke C. HealthLeaders Media. June 6, 2013.

NEWSPAPER/MAGAZINE ARTICLE

Legality of technicians' involvement in medication reconciliation not clear.

Thompson CA. AJHP News. Am J Health Syst Pharm. 2009;66:433-434.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety law protects some documents in court case.

Gallegos A. American Medical News. August 29, 2012.

BOOK/REPORT

HealthGrades Eighth Annual Patient Safety in American Hospitals Study.

Reed K, May R. Denver, CO: HealthGrades, Inc.; March 2011.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

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

STUDY

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial.

Volpp KG, Shea JA, Small DS, et al. JAMA. 2012;308:2208-2217.

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