AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (50)

•Diagnostic Errors (27)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (221)

•Fatigue and Sleep Deprivation (34)

•Medication Safety (288)

•Medical Complications (222)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (72)

•Transfusion Complications (9)

•Psychological and Social Complications (53)

Origin/Sponsor

•Australia and New Zealand (39)

•Europe (204)

•North America (1015)

Resource Types

•Audiovisual (17)

•Book/Report (105)

•Journal Article (901)

•Legislation/Regulation (11)

•Meeting/Conference (6)

•Newspaper/Magazine Article (169)

•Press Release/Announcement (2)

•Special or Theme Issue (11)

•Tools/Toolkit (19)

•Web Resource (27)

Error Types

•Epidemiology of Errors and Adverse Events (340)

•Active Errors (148)

•Latent Errors (102)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (325)

•Legal and Policy Approaches (156)

•Error Reporting and Analysis (371)

•Communication Improvement (327)

•Human Factors Engineering (132)

•Teamwork (81)

•Specialization of Care (100)

•Logistical Approaches (105)

•Culture of Safety (232)

•Technologic Approaches (198)

•Education and Training (227)

Clinical Areas
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Hospital Medicine

Target Audience

•Health Care Providers (688)

•Health Care Executives and Administrators (1035)

•Non-Health Care Professionals (492)

•Patients (119)

Setting of Care

•Hospitals (1257)

•Psychiatric Facilities (4)

•Residential Facilities (7)

•Ambulatory Care (31)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 1276

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COMMENTARY

Early warning systems: the next level of rapid response.

Duncan KD, McMullan C, Mills BM. Nursing. 2012;42:38-44.

STUDY

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

Benin AL, Borgstrom CP, Jenq GY, Roumanis SA, Horwitz LI. BMJ Qual Saf. 2012;21:391-398.

STUDY

Rapid response teams and failure to rescue: one community's experience.

Hammer JA, Jones TL, Brown SA. J Nurs Care Qual. 2012;27:352-358.

STUDY

Sustained effectiveness of a primary-team-based rapid response system.

Howell MD, Ngo L, Folcarelli P, et al. Crit Care Med. 2012;40:2562-2568.

REVIEW

Rapid response systems as a patient safety strategy: a systematic review.

Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Ann Intern Med. 2013;158(5 Part 2):417-425.

STUDY

What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.

Shearer B, Marshall S, Buist MD, et al. BMJ Qual Saf. 2012;21:569-575.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

COMMENTARY

The growth of rapid response systems.

Steel AC, Reynolds SF. Jt Comm J Qual Patient Saf. 2008;34:489-495.

NEWSPAPER/MAGAZINE ARTICLE

Washington Hospital Center safety program seeks to catch 'near-misses.'

Sun LH. Washington Post. August 2, 2011.

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.

MULTI-USE WEBSITE

African Partnerships for Patient Safety.

Geneva, Switzerland: WHO Patient Safety, World Health Organization.

COMMENTARY

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

Clancy CM. Am J Med Qual. 2009;24:344-346.

STUDY

Inpatient fall prevention: use of in-room Webcams.

Hardin SR, Dienemann J, Rudisill P, Mills KK. J Patient Saf. 2013;9:29-35.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals boost patients' power as advisers.

Landro L. Wall Street Journal. August 8, 2007:D1.

COMMENTARY

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Clarke D, Werestiuk K, Schoffner A, et al. J Nurs Manag. 2012;20:592-598.

MEASUREMENT TOOL/INDICATOR

2011 ISMP Medication Safety Self Assessment for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; April 2011.

REVIEW

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

O'Leary KJ, Sehgal NL, Terrell G, Williams MV; High Performance Teams and the Hospital of the Future Project Team. J Hosp Med. 2011 Oct 31; [Epub ahead of print].

STUDY

A review of verbal order policies in acute care hospitals.

Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.

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