AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (7)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (7)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (8)

•Medical Complications (11)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (2)

•Transfusion Complications (1)

•Psychological and Social Complications (2)

Origin/Sponsor

•Australia and New Zealand (4)

•North America (46)

Resource Types

•Book/Report (1)

•Journal Article (49)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (5)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (17)

•Active Errors (13)

•Latent Errors (4)

Approach to Improving Safety

•Quality Improvement Strategies (12)

•Legal and Policy Approaches (2)

•Error Reporting and Analysis (12)

•Communication Improvement (17)

•Human Factors Engineering (6)

•Teamwork (3)

•Specialization of Care (18)

•Logistical Approaches (6)

•Culture of Safety (4)

•Technologic Approaches (8)

•Education and Training (10)

Clinical Areas
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Emergency Medicine

Target Audience

•Health Care Providers (44)

•Health Care Executives and Administrators (38)

•Non-Health Care Professionals (13)

•Patients (2)

Setting of Care

•Hospitals (50)

•Ambulatory Care (3)

•Patient Transport (3)

1 - 20 of 58

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STUDY

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

Hanson CC, Randolph GD, Erickson JA, et al. Qual Saf Health Care. 2009;18:500-504.

COMMENTARY

Experience with family activation of rapid response teams.

Bogert S, Ferrell C, Rutledge DN. Medsurg Nurs. 2010;19:215-222.

STUDY

Single-parameter early warning criteria to predict life-threatening adverse events.

Rothschild JM, Gandara E, Woolf S, Williams DH, Bates DW. J Patient Saf. 2010;6:97-101.

COMMENTARY

Findings of the first consensus conference on medical emergency teams.

Devita MA, Bellomo R, Hillman K, et al. Crit Care Med. 2006;34;2463-2478.

STUDY

A survey of nurses' beliefs about the medical emergency team system in a Canadian tertiary hospital.

Bagshaw SM, Mondor EE, Scouten C, et al; Capital Health Medical Emergency Team Investigators. Am J Crit Care. 2010;19:74-83.

STUDY

Implementation of Condition Help: family teaching and evaluation of family understanding.

Hueckel RM, Mericle JM, Frush K, Martin PL, Champagne MT. J Nurs Care Qual. 2012;27:176-181.

STUDY

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

Santamaria J, Tobin A, Holmes J. Crit Care Med. 2010;38:445-450.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

STUDY

Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy.

Casserly P, Lang E, Fenton JE, Walsh M. Br J Anaesth. 2007;99:380-383.

STUDY

Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension.

Quach JL, Downey AW, Haase M, et al. J Crit Care. 2008;23:325-331.

REVIEW

Nurses' role in detecting deterioration in ward patients: systematic literature review.

Odell M, Victor C, Oliver D. J Adv Nurs. 2009;65:1992-2006.

COMMENTARY

Using an automated risk assessment report to identify patients at risk for clinical deterioration.

Whittington J, White R, Haig KM, Slock M. Jt Comm J Qual Patient Saf. 2007;33:569-574.

STUDY

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

Schenarts PJ, Goettler CE, White MA, Waibel BH. Am Surg. 2012;78:1249-1254.

ORGANIZATIONAL POLICY/GUIDELINES

Joint Policy Statement—Guidelines for Care of Children in the Emergency Department.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2009;124:1233-1243.

STUDY

A survey of the use of time-out protocols in emergency medicine.

Kelly JJ, Farley H, O'Cain C, et al. Jt Comm J Qual Patient Saf. 2011;37:285-288.

REVIEW

classic

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.

COMMENTARY

A serious threat to patient safety: the unintended misuse of FentaNYL patches.

Paparella SF. J Emerg Nurs. 2013;39:245-247.

STUDY

Medication reconciliation in a rural trauma population.

Miller SL, Miller S, Balon J, Helling TS. Ann Emerg Med. 2008;52:483-491.

STUDY

Trauma resuscitation errors and computer-assisted decision support.

Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.

BOOK/REPORT

Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment.

Hsu EB, Jenckes MW, Catlett CL, et al. Summary, Evidence Report/Technology Assessment: Number 95. Rockville, MD: Agency for Healthcare Research and Quality; April 2004. AHRQ Publication Number 04-E015-1.

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