AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (44)

•Identification Errors (42)

•Discontinuities, Gaps, and Hand-Off Problems (49)

•Fatigue and Sleep Deprivation (11)

•Medication Safety (153)

•Medical Complications (77)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (105)

•Transfusion Complications (4)

•Psychological and Social Complications (32)

Origin/Sponsor

•Australia and New Zealand (2)

Resource Types

•Journal Article (63)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (347)

•Press Release/Announcement (8)

•Special or Theme Issue (1)

•Tools/Toolkit (23)

•Web Resource (47)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (46)

•Active Errors (128)

•Latent Errors (42)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (123)

•Legal and Policy Approaches (183)

•Error Reporting and Analysis (178)

•Communication Improvement (191)

•Human Factors Engineering (63)

•Teamwork (17)

•Specialization of Care (22)

•Logistical Approaches (30)

•Culture of Safety (51)

•Technologic Approaches (87)

•Education and Training (127)

Clinical Areas

•Allied Health Services (1)

Target Audience
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Patients

Setting of Care

•Hospitals (346)

•Psychiatric Facilities (3)

•Residential Facilities (7)

•Ambulatory Care (55)

•Outpatient Surgery (10)

•Patient Transport (2)

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NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

MULTI-USE WEBSITE

Quality & Safety Research Group.

Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.

NEWSPAPER/MAGAZINE ARTICLE

M.R.I.'s strong magnets cited in accidents.

McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Prone to error: earliest steps to find cancer.

Saul S. New York Times. July 19, 2010;A1.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

A case that shook medicine.

Lerner BH. The Washington Post. November 28, 2006:HE01.

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals study when to apologize to patients.

Kowalczyk L. The Boston Globe. July 24, 2005.

COMMENTARY

Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.

Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.

MULTI-USE WEBSITE

Collaborating and Acting Responsibly to Ensure Safety (CARES) Alliance.

Covidien.

TOOLKIT

Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit.

Bethesda, MD: Institute for Patient- and Family-Centered Care; 2011.

NEWSPAPER/MAGAZINE ARTICLE

Confronting a colleague who covers up a medical error.

Brody H. Am Fam Physician. 2006;73:1272, 1274.

COMMENTARY

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

Henry LL. Policy Polit Nurs Pract. 2005;6:127-134.

STUDY

Needlestick injuries among surgeons in training.

Makary MA, Al-Attar A, Holzmueller CG, et al. N Engl J Med. 2007;356:2693-2699.

MULTI-USE WEBSITE

The National Report Card on the State of Emergency Medicine.

Dallas, TX: American College of Emergency Physicians.

COMMENTARY classic

A 38-year-old woman with fetal loss and hysterectomy.

Sachs BP. JAMA. 2005;294:833-840.

NEWSPAPER/MAGAZINE ARTICLE

Non-English speakers find ERs hard to reach.

Hua V. San Francisco Chronicle. February 17, 2006:B6.

NEWSPAPER/MAGAZINE ARTICLE

Doctors see flaw in device recalls.

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

COMMENTARY

Appropriate prescribing of medications: an eight-step approach.

Pollock M, Bazaldua OV, Dobbie AE. Am Fam Physician. 2007;75:231-236, 239-240.

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