AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (61)

•Diagnostic Errors (13)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (119)

•Medical Complications (144)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (16)

•Transfusion Complications (3)

•Psychological and Social Complications (5)

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•Australia and New Zealand (30)

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•North America (322)

Resource Types

•Audiovisual (4)

•Book/Report (6)

•Clinical Guideline (1)

•Journal Article (408)

•Newspaper/Magazine Article (26)

•Press Release/Announcement (5)

•Special or Theme Issue (5)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (146)

•Active Errors (76)

•Latent Errors (25)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (111)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (117)

•Communication Improvement (81)

•Human Factors Engineering (84)

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•Logistical Approaches (32)

•Culture of Safety (69)

•Technologic Approaches (59)

•Education and Training (69)

Clinical Areas
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Critical Care

Target Audience

•Health Care Providers (329)

•Health Care Executives and Administrators (379)

•Non-Health Care Professionals (127)

•Patients (21)

Setting of Care

•Hospitals (447)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (2)

•Patient Transport (6)

1 - 20 of 461

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COMMENTARY

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

COMMENTARY

Moving Pains

Schell H, Wachter RM. AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

REVIEW

The high-reliability pediatric intensive care unit.

Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

STUDY

Competence and certification of registered nurses and safety of patients in intensive care units.

Kendall-Gallagher D, Blegen MA. Am J Crit Care. 2009;18:106-113.

STUDY

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.

Valentin A, Capuzzo M, Guidet B, et al; Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. BMJ. 2009;338:b814.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

STUDY

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Pediatrics. 2009;124:945-950.

COMMENTARY

Where’s the Feeding Tube?

Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.

NEWSPAPER/MAGAZINE ARTICLE

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

STUDY

Assessing system failures in operating rooms and intensive care units.

van Beuzekom M, Akerboom SP, Boer F. Qual Saf Health Care. 2007;16:45-50.

STUDY

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study.

Sowan AK, Gaffoor MI, Soeken K, Johantgen ME, Vaidya VU. J Pediatr Nurs. 2010;25:108-118.

COMMENTARY

Code Status Confusion.

Lo B, Tulsky JA. AHRQ WebM&M [serial online]. July 2003.

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