AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (34)

•Diagnostic Errors (44)

•Identification Errors (40)

•Discontinuities, Gaps, and Hand-Off Problems (47)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (144)

•Medical Complications (74)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (102)

•Transfusion Complications (3)

•Psychological and Social Complications (30)

Origin/Sponsor

Resource Types

•Journal Article (54)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (343)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Tools/Toolkit (23)

•Web Resource (40)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (44)

•Active Errors (122)

•Latent Errors (40)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (114)

•Legal and Policy Approaches (179)

•Error Reporting and Analysis (166)

•Communication Improvement (178)

•Human Factors Engineering (59)

•Teamwork (16)

•Specialization of Care (22)

•Logistical Approaches (30)

•Culture of Safety (49)

•Technologic Approaches (84)

•Education and Training (118)

Clinical Areas

•Allied Health Services (1)

Target Audience
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Patients

Setting of Care

•Hospitals (335)

•Psychiatric Facilities (3)

•Residential Facilities (7)

•Ambulatory Care (52)

•Outpatient Surgery (11)

•Patient Transport (2)

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NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

Landro L. Wall Street Journal. February 18, 2009:D1.

AWARD RECIPIENT

Beth Israel cited for improving obstetrics care.

Kowalczyk L. Boston Globe. March 29, 2007:4B.

NEWSPAPER/MAGAZINE ARTICLE

Practicing on patients, real and otherwise.

Chen PW. New York Times. January 28, 2010.

GRANT RECIPIENT

Improving Patient Safety Through Simulation Research.

Rockville, MD: Agency for Healthcare Research and Quality; June 2008.

NEWSPAPER/MAGAZINE ARTICLE

Robots help keep doctors up on skills.

Bohan S. Oakland Tribune. January 27, 2007.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

NEWSPAPER/MAGAZINE ARTICLE

Nurse error spotlights drug's danger.

Greene L. St. Petersburg Times. June 15, 2006:A1.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals try to calm doctors' outbursts: medical road rage affecting patient safety, group says.

Kowalczyk L. The Boston Globe. August 10, 2008;Metro section:1A.

AUDIOVISUAL PRESENTATION classic

First, Do No Harm Part 1: A Case Study of Systems Failure.

Producer: Partnership for Patient Safety & Risk Management Foundation. Chicago, IL: Partnership for Patient Safety; 2000.

NEWSPAPER/MAGAZINE ARTICLE

How could this happen?

Westfall SS, Mascia K. People. October 5, 2009;72:155.

STUDY

Major congenital malformations after first-trimester exposure to ACE inhibitors.

Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. N Engl J Med. 2006;354:2443-2451.

NEWSPAPER/MAGAZINE ARTICLE

To reduce risks, hospitals enlist 'proceduralists.'

Landro L. Wall Street Journal. July 11, 2007:D1.

NEWSPAPER/MAGAZINE ARTICLE

A pinpoint beam strays invisibly, harming instead of healing.

Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.

NEWSPAPER/MAGAZINE ARTICLE

Maternity ward at Highland under fire from patients.

Vesely R. Inside Bay Area. December 28, 2006.

COMMENTARY classic

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

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

AWARD RECIPIENT

Promoting collaboration and transparency in patient safety.

Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.

NEWSPAPER/MAGAZINE ARTICLE

One group of doctors changes its ways.

Hallinan JT. Post-Gazette.com. June 21, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

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

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