AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (64)

•Diagnostic Errors (16)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (65)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (126)

•Medical Complications (169)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (22)

•Transfusion Complications (4)

•Psychological and Social Complications (5)

Origin/Sponsor

•Australia and New Zealand (43)

•Central and South America (5)

•North America (368)

Resource Types

•Audiovisual (4)

•Book/Report (6)

•Clinical Guideline (2)

•Journal Article (467)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (30)

•Press Release/Announcement (5)

•Special or Theme Issue (5)

•Tools/Toolkit (2)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (161)

•Active Errors (80)

•Latent Errors (26)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (122)

•Legal and Policy Approaches (22)

•Error Reporting and Analysis (128)

•Communication Improvement (87)

•Human Factors Engineering (90)

•Teamwork (70)

•Specialization of Care (151)

•Logistical Approaches (33)

•Culture of Safety (71)

•Technologic Approaches (65)

•Education and Training (77)

Clinical Areas
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Critical Care

Target Audience

•Health Care Providers (352)

•Health Care Executives and Administrators (415)

•Non-Health Care Professionals (137)

•Patients (25)

Setting of Care

•Hospitals (504)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (3)

•Patient Transport (6)

1 - 20 of 530

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PRESS RELEASE/ANNOUNCEMENT classic

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AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

STUDY

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Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.

Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. BMJ Qual Saf. 2012;21:737-745.

STUDY

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Intervention to reduce transmission of resistant bacteria in intensive care.

Huskins WC, Huckabee CM, O'Grady NP, et al; STAR*ICU Trial Investigators. N Engl J Med. 2011;364:1407-1418.

STUDY

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The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

Waters HR, Korn R Jr, Colantuoni E, et al. Am J Med Qual. 2011;26:333-339.

STUDY

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Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

REVIEW

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Rapid-response teams.

Jones DA, DeVita MA, Bellomo R. N Engl J Med. 2011;365:139-146.

STUDY

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The effect of multidisciplinary care teams on intensive care unit mortality.

Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. Arch Intern Med. 2010;170:369-376.

STUDY

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Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

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Hospital-wide code rates and mortality before and after implementation of a rapid response team.

Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA. JAMA. 2008;300:2506-2513.

STUDY

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Does the Leapfrog program help identify high-quality hospitals?

Jha AK, Orav EJ, Ridgway AB, Zheng J, Epstein AM. Jt Comm J Qual Patient Saf. 2008;34:318-325.

STUDY

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Delayed time to defibrillation after in-hospital cardiac arrest.

Chan PS, Krumholz HM, Nichol G, Nallamothu BK, and American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. N Engl J Med. 2008;358:9-17.

STUDY

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Improving patient safety in intensive care units in Michigan.

Pronovost PJ, Berenholtz SM, Goeschel C, et al. J Crit Care. 2008;23:207-221.

REVIEW

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Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.

Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. J Hosp Med. 2007;2:422-432.

STUDY

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Costs of adverse events in intensive care units.

Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Crit Care Med. 2007;35:2479-2483.

STUDY

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Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital.

Sharek PJ, Parast LM, Leong K, et al. JAMA. 2007;298:2267-2274.

NEWSPAPER/MAGAZINE ARTICLE classic

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The checklist.

Gawande A. The New Yorker. December 10, 2007;83:86-95.

STUDY

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Explaining Michigan: developing an ex post theory of a quality improvement program.

Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.

REVIEW

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Rapid response teams: a systematic review and meta-analysis.

Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Arch Intern Med. 2010;170:18-26.

COMMENTARY classic

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Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.

STUDY

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Perceptions of safety culture vary across the intensive care units of a single institution.

Huang DT, Clermont G, Sexton JB, et al. Crit Care Med. 2007;35:165-176.

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