AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (53)

•Diagnostic Errors (27)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (226)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (297)

•Medical Complications (226)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (71)

•Transfusion Complications (9)

•Psychological and Social Complications (53)

Origin/Sponsor

•Australia and New Zealand (41)

•Europe (208)

•North America (1037)

Resource Types

•Audiovisual (18)

•Book/Report (106)

•Journal Article (921)

•Legislation/Regulation (11)

•Meeting/Conference (7)

•Newspaper/Magazine Article (174)

•Press Release/Announcement (2)

•Special or Theme Issue (12)

•Tools/Toolkit (19)

•Web Resource (28)

Error Types

•Epidemiology of Errors and Adverse Events (348)

•Active Errors (156)

•Latent Errors (111)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (331)

•Legal and Policy Approaches (157)

•Error Reporting and Analysis (379)

•Communication Improvement (332)

•Human Factors Engineering (133)

•Teamwork (84)

•Specialization of Care (103)

•Logistical Approaches (107)

•Culture of Safety (233)

•Technologic Approaches (201)

•Education and Training (232)

Clinical Areas
< All

Hospital Medicine

Target Audience

•Health Care Providers (702)

•Health Care Executives and Administrators (1063)

•Non-Health Care Professionals (503)

•Patients (122)

Setting of Care

•Hospitals (1286)

•Psychiatric Facilities (4)

•Residential Facilities (7)

•Ambulatory Care (32)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 1306

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STUDY

classic

A survey of the impact of disruptive behaviors and communication defects on patient safety.

Rosenstein AH, O'Daniel M. Jt Comm J Qual Patient Saf. 2008;34:464-471.

ORGANIZATIONAL POLICY/GUIDELINES

Leadership committed to safety.

Sentinel Event Alert. August 27, 2009;(43):1-3.

STUDY

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.

Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

COMMENTARY

Leading a highly visible hospital through a serious reportable event.

Erickson JI. J Nurs Adm. 2012;42:131-133.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

FACT SHEET/FAQS

2012 Hospital National Patient Safety Goals.

Oakbrook Terrace, IL: Joint Commission; 2011.

COMMENTARY

Debriefing medical teams: 12 evidence-based best practices and tips.

Salas E, Klein C, King H, et al. Jt Comm J Qual Patient Saf. 2008;34:518-527.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

STUDY

classic

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.

STUDY

Hospital performance trends on national quality measures and the association with Joint Commission accreditation.

Schmaltz SP, Williams SC, Chassin MR, Loeb JM, Wachter RM. J Hosp Med. 2011;6:458-465.

MULTI-USE WEBSITE

Joint Commission Center for Transforming Healthcare.

The Joint Commission.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

AUDIOVISUAL PRESENTATION

North Carolina Just Culture Journey.

Plano, TX: Just Culture Community; November 2008.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

BOOK/REPORT

Medical Team Training.

Oakbrook, IL: Joint Commission Resources; 2008. ISBN: 9781599400921.

NEWSPAPER/MAGAZINE ARTICLE

Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.

Collins TR. The Hospitalist. July 2011.

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