AHRQ Patient Safety Network

The Collection > Policy Makers

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (16)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (27)

•Fatigue and Sleep Deprivation (19)

•Medication Safety (87)

•Medical Complications (71)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (50)

•Transfusion Complications (2)

•Psychological and Social Complications (12)

Origin/Sponsor

•Africa (3)

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•Australia and New Zealand (12)

•Central and South America (2)

Resource Types

•Journal Article (276)

•Legislation/Regulation (17)

•Meeting/Conference (12)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (73)

•Press Release/Announcement (5)

•Special or Theme Issue (10)

•Tools/Toolkit (5)

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Error Types

•Epidemiology of Errors and Adverse Events (72)

•Active Errors (30)

•Latent Errors (35)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (148)

•Legal and Policy Approaches (288)

•Error Reporting and Analysis (251)

•Communication Improvement (65)

•Human Factors Engineering (34)

•Teamwork (27)

•Specialization of Care (10)

•Logistical Approaches (34)

•Culture of Safety (88)

•Technologic Approaches (84)

•Education and Training (78)

Clinical Areas

•Allied Health Services (1)

•Medicine (222)

•Nursing (9)

•Pharmacy (29)

Target Audience
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Policy Makers

Setting of Care

•Hospitals (224)

•Psychiatric Facilities (2)

•Residential Facilities (10)

•Ambulatory Care (35)

•Outpatient Surgery (10)

•Patient Transport (1)

1 - 20 of 532

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COMMENTARY

Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.

Milstein A. Health Aff (Millwood). 2007;26:w236-w241.

NEWSPAPER/MAGAZINE ARTICLE

Still hard to share. PSOs making progress but still face tech hurdles.

DerGurahian J. Mod Healthc. October 12, 2009;39:30.

REVIEW

Informatics confronts drug–drug interactions.

Percha B, Altman RB. Trends Pharmacol Sci. 2013;34:178-184.

COMMENTARY

Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians.

Koppel R, Kreda D. JAMA. 2009;301:1276-1278.

COMMENTARY

Meaningful use and certification of health information technology: what about safety?

Hoffman S, Podgurski A. J Law Med Ethics. 2011;39(suppl 1):77-80.

STUDY

The long road to patient safety: a status report on patient safety systems.

Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.

COMMENTARY

From tasks to processes: the case for changing health information technology to improve health care.

Walker JM, Carayon P. Health Aff. 2009;28:467-477.

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.

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

BOOK/REPORT

Maximizing the Use of State Adverse Event Data to Improve Patient Safety.

Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; 2005.

ORGANIZATIONAL POLICY/GUIDELINES

Leadership committed to safety.

Sentinel Event Alert. August 27, 2009;(43):1-3.

COMMENTARY

Knowledge-based information to improve the quality of patient care.

Garcia JL, Wells KK. J Healthc Qual. 2009;31:30-35.

COMMENTARY

Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

Nair V, Salmon JW, Kaul AF. Dis Manage. 2007;10:337-346.

NEWSPAPER/MAGAZINE ARTICLE

FDA discusses oversight, regulation of HIT at ONC Workgroup hearing on patient safety.

Health IT Law & Industry Report; February 26, 2010.

STUDY

Relationship between occurrence of surgical complications and hospital finances.

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

STUDY

Toward higher-performance health systems: adults' health care experiences in seven countries, 2007.

Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Health Aff (Millwood). 2007;26:w717–w734.

STUDY

Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants.

Bismark MM, Brennan TA, Davis PB, Studdert DM. Med J Aust. 2006;185:203-207.

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.

REVIEW

Hospital-based medication reconciliation practices: a systematic review.

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.

COMMENTARY

Measuring preventable harm: helping science keep pace with policy.

Pronovost PJ, Colantuoni E. JAMA. 2009;301:1273-1275.

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