AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (51)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (95)

•Medical Complications (81)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (17)

•Transfusion Complications (1)

•Psychological and Social Complications (6)

Origin/Sponsor

•Australia and New Zealand (39)

•Central and South America (1)

•North America (302)

Resource Types

•Book/Report (9)

•Journal Article (344)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (32)

•Special or Theme Issue (4)

•Tools/Toolkit (5)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (120)

•Active Errors (91)

•Latent Errors (26)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (83)

•Legal and Policy Approaches (22)

•Error Reporting and Analysis (79)

•Communication Improvement (100)

•Human Factors Engineering (41)

•Teamwork (53)

•Specialization of Care (110)

•Logistical Approaches (28)

•Culture of Safety (24)

•Technologic Approaches (35)

•Education and Training (88)

Clinical Areas
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Emergency Medicine

Target Audience

•Health Care Providers (304)

•Health Care Executives and Administrators (300)

•Non-Health Care Professionals (111)

•Patients (18)

Setting of Care

•Hospitals (357)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (18)

•Patient Transport (36)

1 - 20 of 401

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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].

COMMENTARY

Code Status Confusion.

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

STUDY

Flow disruptions in trauma care handoffs.

Catchpole KR, Gangi A, Blocker RC, et al. J Surg Res. 2013 Mar 13; [Epub ahead of print].

COMMENTARY

To LP or not LP.

Landrigan CP. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

Lethal Vertigo.

Furman JM. AHRQ WebM&M [serial online]. June 2004.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

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

Undertriage of elderly trauma patients to state-designated trauma centers.

Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Arch Surg. 2008;143:776-781.

STUDY

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. J Hosp Med. 2011;6:68-72.

MULTI-USE WEBSITE

Safer Sign Out.

Emergency Medicine Patient Safety Foundation.

COMMENTARY

Undiagnosed Vaginal Bleeding.

Mandelblatt J. AHRQ WebM&M [serial online]. February 2004.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

COMMENTARY

To Transfer or Not to Transfer

Pines JM. AHRQ WebM&M [serial online]. January 2009.

COMMENTARY

Code Blue—Where To?

Adams BD. AHRQ WebM&M [serial online]. October 2007.

REVIEW

Clinical handover of patients arriving by ambulance to the emergency department: a literature review.

Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Int Emerg Nurs. 2010;18:210-220.

STUDY

classic

Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial.

MERIT study investigators. Lancet. 2005;365:2091-2097.

COMMENTARY

Improving handoffs in the emergency department.

Cheung DS, Kelly JJ, Beach C, et al; American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Ann Emerg Med. 2010;55:171-180.

COMMENTARY

The Dropped Lung.

Heffner JE. AHRQ WebM&M [serial online]. May 2003.

COMMENTARY

Crushing Chest Pain: A Missed Opportunity.

Graber M. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

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