AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (55)

•Diagnostic Errors (13)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (42)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (106)

•Medical Complications (90)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (13)

•Transfusion Complications (3)

•Psychological and Social Complications (3)

Origin/Sponsor

•Australia and New Zealand (14)

•Central and South America (4)

•North America (253)

Resource Types

•Audiovisual (2)

•Book/Report (3)

•Clinical Guideline (2)

•Journal Article (324)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (18)

•Press Release/Announcement (5)

•Special or Theme Issue (4)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (130)

•Active Errors (66)

•Latent Errors (22)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (91)

•Legal and Policy Approaches (15)

•Error Reporting and Analysis (104)

•Communication Improvement (68)

•Human Factors Engineering (69)

•Teamwork (53)

•Specialization of Care (48)

•Logistical Approaches (27)

•Culture of Safety (57)

•Technologic Approaches (47)

•Education and Training (54)

Clinical Areas
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Critical Care

Target Audience

•Health Care Providers (249)

•Health Care Executives and Administrators (288)

•Non-Health Care Professionals (106)

•Patients (13)

Setting of Care

•Hospitals (350)

•Residential Facilities (1)

•Ambulatory Care (3)

•Patient Transport (5)

1 - 20 of 361

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COMMENTARY

In Conversation with…Christopher P. Landrigan, MD

AHRQ WebM&M [serial online]. April 2005.

COMMENTARY

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Pastores SM, O’Connor MF, Kleinpell RM, et al. Crit Care Med. 2011;39:2540-2549.

STUDY

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units.

Parshuram CS, Kirpalani H, Mehta S, Granton J, Cook D, for the Canadian Critical Care Trials Group. Crit Care Med. 2006;34:1674-78.

NEWSPAPER/MAGAZINE ARTICLE

Intensivists: an Rx for the ICU?

Meyers S. Trustee. March 2006;59:29-30.

STUDY

Communication in critical care environments: mobile telephones improve patient care.

Soto RG, Chu LF, Goldman JM, Rampil IJ, Ruskin KJ. Anesth Analg. 2006;102:535-541.

STUDY

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit.

Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-861.

STUDY

An observational study of changes to long-term medication after admission to an intensive care unit.

Campbell AJ, Bloomfield R, Noble DW. Anaesthesia. 2006;61:1087-1092.

COMMENTARY

In Conversation with…Peter J. Pronovost, MD, PhD

AHRQ WebM&M [serial online]. June 2005.

STUDY

Interruptive communication patterns in the intensive care unit ward round.

Alvarez G, Coiera E. Int J Med Inform. 2005;74:791-796.

STUDY

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

Needham DM, Sinopoli DJ, Thompson DA, et al. Crit Care Med. 2005;33:1701-1707.

STUDY

Speaking up and sharing information improves trainee neonatal resuscitations.

Katakam LI, Trickey AW, Thomas EJ. J Patient Saf. 2012;8:202-209.

STUDY

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Crit Care Med. 2006;34:1016-1024.

REVIEW

Failure mode and effects analysis application to critical care medicine.

Duwe B, Fuchs BD, Hansen-Flaschen J. Crit Care Clin. 2005;21:21-30, vii.

STUDY

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

Buckley MS, Erstad BL, Kopp BJ, Theodorou AA, Priestley G. Pediatr Crit Care Med. 2007;8:145-152.

STUDY

classic

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

Design and implementation of an ICU incident registry.

van der Veer S, Cornet R, de Jonge E. Int J Med Inform. 2007;76:103-108.

STUDY

Implementing and validating a comprehensive unit-based safety program.

Pronovost P, Weast B, Rosenstein B. J Patient Saf. 2005;1:33-40.

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