AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (38)

•Diagnostic Errors (44)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (51)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (167)

•Medical Complications (83)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (114)

•Transfusion Complications (3)

•Psychological and Social Complications (35)

Origin/Sponsor

•Australia and New Zealand (7)

Resource Types

•Journal Article (72)

•Legislation/Regulation (9)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (357)

•Press Release/Announcement (10)

•Special or Theme Issue (1)

•Tools/Toolkit (27)

•Web Resource (55)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (56)

•Active Errors (127)

•Latent Errors (49)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (139)

•Legal and Policy Approaches (204)

•Error Reporting and Analysis (203)

•Communication Improvement (197)

•Human Factors Engineering (65)

•Teamwork (20)

•Specialization of Care (23)

•Logistical Approaches (31)

•Culture of Safety (62)

•Technologic Approaches (93)

•Education and Training (132)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Patients

Setting of Care

•Hospitals (374)

•Psychiatric Facilities (3)

•Residential Facilities (9)

•Ambulatory Care (57)

•Outpatient Surgery (12)

•Patient Transport (2)

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NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

COMMENTARY

Our broken health care system and how to fix it: an essay on health law and policy.

Jost TS. Wake Forest Law Rev. 2006;41:537-618.

REVIEW

Role of intraoperative cholangiography in avoiding bile duct injury.

Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.

BOOK/REPORT

To Err Is Human — To Delay Is Deadly.

Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.

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

New practices reduce childbirth risks.

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

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

Collins D. Associated Press [MSNBC]. July 26, 2007.

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.

NEWSPAPER/MAGAZINE ARTICLE

Report: hospital errors cost 18 lives.

Rojas-Burke J. Oregonian. January 30, 2007:B01.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

Franklin D. New York Times. October 25, 2005:F1.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

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

NEWSPAPER/MAGAZINE ARTICLE

Hospitals save money, but safety is questioned.

Klein A. The Washington Post. December 11, 2005:A01.

STUDY

Patient misidentification in the neonatal intensive care unit: quantification of risk.

Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.

NEWSPAPER/MAGAZINE ARTICLE

Preventing fatal errors.

Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.

NEWSPAPER/MAGAZINE ARTICLE

One group of doctors changes its ways.

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

NEWSPAPER/MAGAZINE ARTICLE

Fires during surgeries a bigger risk than thought.

Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.

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