AHRQ Patient Safety Network

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Safety Target

•Diagnostic Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (10)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (20)

•Medical Complications (5)

•Surgical Complications (1)

•Psychological and Social Complications (13)

Origin/Sponsor

•Australia and New Zealand (1)

•North America (44)

Resource Types

•Book/Report (2)

•Journal Article (60)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (4)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (21)

•Active Errors (14)

•Latent Errors (3)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (13)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (28)

•Communication Improvement (16)

•Human Factors Engineering (4)

•Teamwork (5)

•Specialization of Care (3)

•Logistical Approaches (6)

•Culture of Safety (4)

•Technologic Approaches (3)

•Education and Training (17)

Clinical Areas
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Mental Health Care (Psychiatry & Clinical Psychology)

Target Audience

•Health Care Providers (50)

•Health Care Executives and Administrators (45)

•Non-Health Care Professionals (17)

•Patients (4)

Setting of Care

•Hospitals (24)

•Psychiatric Facilities (25)

•Residential Facilities (3)

•Ambulatory Care (12)

1 - 20 of 68

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STUDY

classic

Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.

DesRoches CM, Rao SR, Fromson JA, et al. JAMA. 2010;304:187-193.

STUDY

classic

Hindsight ≠ foresight: the effect of outcome knowledge on judgment under uncertainty.

Fischoff B. J Exper Psychol: Hum Perfor Percept. 1975;1:288-299.

STUDY

Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.

Jayaram G, Doyle D, Steinwachs D, Samuels J. J Psychiatr Pract. 2011;17:81–88.

ORGANIZATIONAL POLICY/GUIDELINES

A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department.

Sentinel Event Alert. 2010 Nov 17;(46):1-4.

STUDY

A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals.

Mills PD, Watts BV, Miller S, et al. Jt Comm J Qual Patient Saf. 2010;36:87-93.

STUDY

Factors associated with intern fatigue.

Friesen LD, Vidyarthi AR, Baron RB, Katz PP. J Gen Intern Med. 2008;23:1981-1986.

STUDY

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.

Mills PD, DeRosier JM, Ballot BA, Shepherd M, Bagian JP. Jt Comm J Qual Patient Saf. 2008;34:482-488.

BOOK/REPORT

With Safety in Mind: Mental Health Services and Patient Safety.

Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.

DATABASE/DIRECTORY

National Inventory of Mental Health Quality Measures.

Tufts-New England Medical Center, Tufts University School of Medicine, and Harvard University: Center for Quality Assessment & Improvement in Mental Health; 2011.

REVIEW

Patient safety in psychiatric inpatient care: a literature review.

Kanerva A, Lammintakanen J, Kivinen T. J Psychiatr Ment Health Nurs. 2012 Jul 8; [Epub ahead of print].

STUDY

Supporting a psychiatric hospital culture of safety.

Mahoney JS, Ellis TE, Garland G, Palyo N, Greene PK. J Am Psychiatr Nurses Assoc. 2012;18:299-306.

STUDY

Dementia and risk of adverse warfarin-related events in the nursing home setting.

Tjia J, Field TS, Mazor KM, et al. Am J Geriatr Pharmacother. 2012;10:323-330.

STUDY

Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications.

Smith EG, Zhao S, Rosen AK. Int J Qual Health Care. 2012;24:321-329.

STUDY

Electronic medical record availability and primary care depression treatment.

Harman JS, Rost KM, Harle CA, Cook RL. J Gen Intern Med. 2012;27:962-967.

STUDY

Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia.

Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. Am J Alzheimers Dis Other Demen. 2011;26:606-615.

STUDY

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.

NEWSPAPER/MAGAZINE ARTICLE

Hospital mistakes kept secret.

Judd A. The Atlanta Journal-Constitution. November 20, 2011.

STUDY

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer.

Young JQ, Pringle Z, Wachter RM. Jt Comm J Qual Patient Saf. 2011;37:300-308.

STUDY

What near misses tell us about risk and safety in mental health care.

Jeffs L, Rose D, Macrae C, Maione M, Macmillan KM. J Psychiatr Ment Health Nurs. 2012;19:430-437.

STUDY

Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses.

Mendel R, Traut-Mattausch E, Jonas E, et al. Psychol Med. 2011;41:2651-2659.

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