AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (40)

•Diagnostic Errors (47)

•Identification Errors (47)

•Discontinuities, Gaps, and Hand-Off Problems (53)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (176)

•Medical Complications (87)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (115)

•Transfusion Complications (4)

•Psychological and Social Complications (37)

Origin/Sponsor

•Australia and New Zealand (6)

Resource Types

•Journal Article (74)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (357)

•Press Release/Announcement (11)

•Special or Theme Issue (1)

•Tools/Toolkit (26)

•Web Resource (57)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (58)

•Active Errors (134)

•Latent Errors (51)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (142)

•Legal and Policy Approaches (199)

•Error Reporting and Analysis (201)

•Communication Improvement (201)

•Human Factors Engineering (65)

•Teamwork (20)

•Specialization of Care (23)

•Logistical Approaches (32)

•Culture of Safety (60)

•Technologic Approaches (94)

•Education and Training (134)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Patients

Setting of Care

•Hospitals (370)

•Psychiatric Facilities (3)

•Residential Facilities (8)

•Ambulatory Care (59)

•Outpatient Surgery (12)

•Patient Transport (2)

1 - 20 of 675

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COMMENTARY classic

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

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

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

Nurse is charged in death of patient.

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

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

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

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

Nurse error spotlights drug's danger.

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

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

Robots help keep doctors up on skills.

Bohan S. Oakland Tribune. January 27, 2007.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

200 epidural blunders admitted after three women die.

Oakeshott I. The Sunday Times. June 18, 2006.

COMMENTARY

Surgical site verification: A through Z.

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

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

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

BOOK/REPORT

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

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

NEWSPAPER/MAGAZINE ARTICLE

Maternity ward at Highland under fire from patients.

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

NEWSPAPER/MAGAZINE ARTICLE

Cause of death: sloppy doctors.

Caplan J. Time.com. January 15, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Reused devices, surgery's deadly suspects.

Klein A. The Washington Post. December 30, 2005:A3.

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

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Fatal drug mix-up exposes hospital flaws.

Davies T. Washington Post. September 22, 2006.

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