AHRQ Patient Safety Network

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Safety Target

•Diagnostic Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (8)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (11)

•Medical Complications (4)

•Surgical Complications (1)

•Psychological and Social Complications (7)

Origin/Sponsor

•North America (29)

Resource Types

•Book/Report (2)

•Journal Article (38)

•Newspaper/Magazine Article (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (12)

•Active Errors (12)

•Latent Errors (3)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (12)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (17)

•Communication Improvement (8)

•Human Factors Engineering (3)

•Teamwork (3)

•Specialization of Care (1)

•Logistical Approaches (5)

•Culture of Safety (3)

•Technologic Approaches (3)

•Education and Training (12)

Clinical Areas
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Mental Health Care (Psychiatry & Clinical Psychology)

Target Audience

•Health Care Providers (39)

•Health Care Executives and Administrators (30)

•Non-Health Care Professionals (9)

•Patients (1)

Setting of Care

•Hospitals (20)

•Psychiatric Facilities (16)

•Residential Facilities (1)

•Ambulatory Care (8)

1 - 20 of 42

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COMMENTARY

When “Psychiatric” Symptoms are Not.

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

COMMENTARY

Code Blue—Where To?

Adams BD. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

STUDY

Diagnostic errors and temporal stability in bipolar disorder.

López J, Baca E, Botillo C, et al. Actas Esp Psiquiatr. 2008;36:205-209.

REVIEW

Inpatient suicide: preventing a common sentinel event.

Tishler CL, Reiss NS. Gen Hosp Psychiatry. 2009;31:103-109.

STUDY

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

COMMENTARY

The 2-Week Itch.

Cohen MR. AHRQ WebM&M [serial online]. April 2003.

BOOK/REPORT

Safety in Doses.

London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.

STUDY

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

COMMENTARY

Delirium or Dementia?

Rudolph JL. AHRQ WebM&M [serial online]. May 2009.

COMMENTARY

Don't Push.

Meltzer HY. AHRQ WebM&M [serial online]. November 2003.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

COMMENTARY

Suicidal Man with Gun.

Simon RI. AHRQ WebM&M [serial online]. May 2003.

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.

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.

COMMENTARY

Environmental changes increase hospital safety for dementia patients.

Goodall D. Holist Nurs Pract. March/April 2006;20:80-84.

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.

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.

COMMENTARY

Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons from the suicide of a psychiatric patient.

Young JQ, Eisendrath SJ. Acad Psychiatry. 2011;35:54-57.

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.

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