AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (10)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (40)

•Medication Safety (101)

•Medical Complications (22)

•Surgical Complications (5)

•Transfusion Complications (1)

•Psychological and Social Complications (7)

Origin/Sponsor

•Australia and New Zealand (5)

•North America (131)

Resource Types

•Audiovisual (1)

•Book/Report (4)

•Clinical Guideline (2)

•Journal Article (153)

•Meeting/Conference (1)

•Newspaper/Magazine Article (4)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (71)

•Active Errors (30)

•Latent Errors (13)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (34)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (40)

•Communication Improvement (59)

•Human Factors Engineering (14)

•Teamwork (4)

•Specialization of Care (13)

•Logistical Approaches (11)

•Culture of Safety (25)

•Technologic Approaches (39)

•Education and Training (30)

Clinical Areas
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Geriatrics

Target Audience

•Health Care Providers (143)

•Health Care Executives and Administrators (133)

•Non-Health Care Professionals (42)

•Patients (5)

Setting of Care

•Hospitals (68)

•Psychiatric Facilities (3)

•Residential Facilities (82)

•Ambulatory Care (36)

•Patient Transport (1)

1 - 20 of 176

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STUDY

Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.

Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.

STUDY

Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety.

Castle NG, Wagner LM, Perera S, Ferguson JC, Handler SM. J Patient Saf. 2010;6:59-67.

STUDY

Nurse aides' ratings of the resident safety culture in nursing homes.

Castle NG. Int J Qual Health Care. 2006;18:370-6.

COMMENTARY

Fumbled Handoff.

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

STUDY

Organizational climate determinants of resident safety culture in nursing homes.

Arnetz JE, Zhdanova LS, Elsouhag D, Lichtenberg P, Luborsky MR, Arnetz BB. Gerontologist. 2011;51:739-749.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

COMMENTARY

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

STUDY

Relationship between quality of care and negligence litigation in nursing homes.

Studdert DM, Spittal MJ, Mello MM, O’Malley AJ, Stevenson DG. N Engl J Med. 2011;364:1243-1250.

STUDY

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

Rochon PA, Field TS, Bates DW, et al. J Am Geriatr Soc. 2005;53:1780-1789.

STUDY

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.

Alldred DP, Standage C, Fletcher O, et al. BMJ Qual Saf. 2011;20:397-402.

STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

TOOLKIT

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.

STUDY

Measuring administrators' and direct care workers' perceptions of the safety culture in assisted living facilities.

Castle NG, Wagner LM, Sonon K, Ferguson-Rome JC. Jt Comm J Qual Patient Saf. 2012;38:375-385.

STUDY

Measuring safety climate in elderly homes.

Yeung KC, Chan CC. J Safety Res. 2012;43:9-20.

STUDY

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

STUDY

Nursing home administrators' opinions of the resident safety culture in nursing homes.

Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

MEASUREMENT TOOL/INDICATOR

Survey User's Guide: Nursing Home Survey on Patient Safety Culture.

Sorra J, Franklin M, Streagle S. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0060.

TOOLKIT

Improving Medication Safety in High Risk Medicare Beneficiaries Toolkit.

Touchette DR, Stubbings J, Schumock G. Effective Healthcare Research Report No. 38. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-EHC027-EF.

COMMENTARY

Inadvertent Castration.

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

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