AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (11)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (38)

•Medication Safety (92)

•Medical Complications (21)

•Surgical Complications (6)

•Transfusion Complications (1)

•Psychological and Social Complications (6)

Origin/Sponsor

•Australia and New Zealand (4)

•North America (115)

Resource Types

•Audiovisual (1)

•Book/Report (5)

•Clinical Guideline (2)

•Journal Article (130)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (10)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (63)

•Active Errors (34)

•Latent Errors (15)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (37)

•Legal and Policy Approaches (12)

•Error Reporting and Analysis (28)

•Communication Improvement (64)

•Human Factors Engineering (14)

•Teamwork (2)

•Specialization of Care (12)

•Logistical Approaches (10)

•Culture of Safety (18)

•Technologic Approaches (32)

•Education and Training (30)

Clinical Areas
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Geriatrics

Target Audience

•Health Care Providers (137)

•Health Care Executives and Administrators (105)

•Non-Health Care Professionals (35)

•Patients (9)

Setting of Care

•Hospitals (80)

•Psychiatric Facilities (1)

•Residential Facilities (51)

•Ambulatory Care (39)

•Patient Transport (1)

1 - 20 of 162

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COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

The Dropped Lung.

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

COMMENTARY

Lesar TS. AHRQ WebM&M [serial online]. November 2003.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

When “Psychiatric” Symptoms are Not.

Goldberg RJ. AHRQ WebM&M [serial online]. February 2003.

COMMENTARY

Another Fall.

Bogardus ST Jr. AHRQ WebM&M [serial online]. April 2003.

NEWSPAPER/MAGAZINE ARTICLE

Keeping track of aging patients’ medications.

Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.

NEWSPAPER/MAGAZINE ARTICLE

Difficulty identifying Alzheimer's makes misdiagnosis easy.

Ackerman T. Houston Chronicle. November 23, 2012.

AUDIOVISUAL

Healthcare 411: Making hospital discharges safer for seniors.

Rockville, MD: Agency for Healthcare Research and Quality. June 3, 2009.

COMMENTARY

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

STUDY

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2012 Sep 7; [Epub ahead of print].

STUDY

Failure to engage hospitalized elderly patients and their families in advance care planning.

Heyland DK, Barwich D, Pichora D, et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). JAMA Intern Med. 2013 Apr 1; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

Nursing homes seen deficient on basic care.

Dembner A. Boston Globe. July 3, 2006;Health Science section:A1.

BOOK/REPORT

Improving Patient Safety in Long-Term Care Facilities: Training Modules.

Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0001.

STUDY

Older adults' perceptions of feeling safe in urban and rural acute care.

Lasiter S, Duffy J. J Nurs Adm. 2013;43:30-66.

COMMENTARY

Mistaken Identity

Hall LW. AHRQ WebM&M [serial online]. October 2008.

COMMENTARY

Discharged Blindly

Iezzoni LI. AHRQ WebM&M [serial online]. December 2005.

NEWSPAPER/MAGAZINE ARTICLE

Staying safe during a hospital stay.

Graham J. Los Angeles Times. May 11, 2011.

STUDY

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

STUDY

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.

Sari AB, Cracknell A, Sheldon TA. Age Ageing. 2008;37:265-269.

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