AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (31)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (44)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (89)

•Medical Complications (9)

•Surgical Complications (1)

•Psychological and Social Complications (12)

Origin/Sponsor

•Australia and New Zealand (8)

•North America (159)

Resource Types

•Audiovisual (3)

•Book/Report (10)

•Clinical Guideline (1)

•Journal Article (205)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (8)

•Tools/Toolkit (6)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (72)

•Active Errors (36)

•Latent Errors (4)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (49)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (70)

•Communication Improvement (81)

•Human Factors Engineering (11)

•Teamwork (20)

•Specialization of Care (7)

•Logistical Approaches (16)

•Culture of Safety (20)

•Technologic Approaches (66)

•Education and Training (37)

Clinical Areas
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Family Medicine

Target Audience

•Health Care Providers (172)

•Health Care Executives and Administrators (139)

•Non-Health Care Professionals (96)

•Patients (10)

Setting of Care

•Hospitals (31)

•Psychiatric Facilities (2)

•Residential Facilities (2)

•Ambulatory Care (187)

1 - 20 of 236

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REVIEW

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Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

BOOK/REPORT

Safety in Doses.

London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

STUDY

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The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

STUDY

Post-discharge medication reviews for patients with heart failure: a pilot study.

Ponniah A, Shakib S, Doecke CJ, Boyce M, Angley M. Pharm World Sci. 2008;30:810-815.

REVIEW

Routinely recorded patient safety events in primary care: a literature review.

Tsang C, Majeed A, Aylin P. Fam Pract. 2012;29:8-15.

STUDY

classic

Information exchange among physicians caring for the same patient in the community.

van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.

STUDY

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

Bell CM, Schnipper JL, Auerbach AD, et al. J Gen Intern Med. 2009;24:381-386.

BOOK/REPORT

Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report.

The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.

STUDY

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

Staroselsky M, Volk LA, Tsurikova R, et al. Int J Med Inform. 2008;77:153-160.

STUDY

Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands.

Leendertse AJ, Egberts ACG, Stoker LJ, van den Bemt PMLA, for the HARM Study Group. Arch Intern Med. 2008;168:1890-1896.

STUDY

Improving medication safety in primary care using electronic health records.

Nemeth LS, Wessell AM. J Patient Saf. 2010;6:238-243.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.

Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

STUDY

Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events.

Metlay JP, Hennessy S, Localio AR, et al. J Gen Intern Med. 2008;23:1589-1594.

STUDY

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

McDonald KM, Davies SM, Haberland CA, et al. Pediatrics. 2008;122:e416-e425.

STUDY

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

Stephens M, Fox B, Kukulka G, Bellamy J. Fam Medicine. 2008;40:107-110.

STUDY

Implementing medication reconciliation in outpatient pediatrics.

Rappaport DI, Collins B, Koster A, et al. Pediatrics. 2011;128:e1600-e1607.

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