AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (3)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (9)

•Medical Complications (8)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (1)

•Psychological and Social Complications (2)

Origin/Sponsor

•North America (30)

Resource Types

•Audiovisual (1)

•Clinical Guideline (1)

•Journal Article (27)

•Newspaper/Magazine Article (3)

•Press Release/Announcement (2)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (10)

•Active Errors (15)

•Latent Errors (3)

Approach to Improving Safety

•Quality Improvement Strategies (12)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (7)

•Communication Improvement (6)

•Human Factors Engineering (1)

•Teamwork (1)

•Specialization of Care (6)

•Logistical Approaches (3)

•Culture of Safety (1)

•Technologic Approaches (4)

•Education and Training (8)

Clinical Areas
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Neurology

Target Audience

•Health Care Providers (28)

•Health Care Executives and Administrators (17)

•Non-Health Care Professionals (7)

•Patients (5)

Setting of Care

•Hospitals (20)

•Residential Facilities (1)

•Ambulatory Care (6)

•Outpatient Surgery (1)

1 - 20 of 35

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STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

STUDY

Did duty hour reform lead to better outcomes among the highest risk patients?

Volpp KG, Rosen AK, Rosenbaum PR, et al. J Gen Intern Med. 2009;10:1149-1155.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

STUDY

The cost of pneumonia after acute stroke.

Katzan IL, Dawson NV, Thomas CL, Votruba ME, Cebul RD. Neurology. 2007;68:1938-1943.

STUDY

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. J Gen Intern Med. 2006;21:758-763.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

COMMENTARY

"Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist?

Benbadis SR. Neurology. 2013;80(suppl 1):S47-S51.

CLINICAL GUIDELINE classic

classic

Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.

Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.

MULTI-USE WEBSITE

American Pain Foundation.

STUDY

Medication errors in the homes of children with chronic conditions.

Walsh KE, Mazor KM, Stille CJ, et al. Arch Dis Child. 2011;96:581-586.

STUDY

Factors associated with misdiagnosis of acute stroke in young adults.

Kuruvilla A, Bhattacharya P, Rajamani K, Chaturvedi S. J Stroke Cerebrovasc Dis. 2011;20:523-527.

STUDY

Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents.

Bertsche T, Bertsche A, Krieg EM, et al. Qual Saf Health Care. 2010;19:e26.

COMMENTARY

Lethal Vertigo.

Furman JM. AHRQ WebM&M [serial online]. June 2004.

PRESS RELEASE/ANNOUNCEMENT

CT brain perfusion scans safety investigation: initial notification.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

COMMENTARY

NFL concussions and common sense: a recipe for medical errors and a lesson for physician leaders.

Lazarus A. Physician Exec. Jan-Feb 2011;37:6-9.

NEWSPAPER/MAGAZINE ARTICLE

Difficulty identifying Alzheimer's makes misdiagnosis easy.

Ackerman T. Houston Chronicle. November 23, 2012.

STUDY

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

Smith ER, Butler WE, Barker FG 2nd. J Neurosurg. 2006;105(suppl 3):169-176.

PRESS RELEASE/ANNOUNCEMENT

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.

COMMENTARY

The Forgotten Drip

Josephson SA. AHRQ WebM&M [serial online]. January 2008.

COMMENTARY

Antiseizure Medication Disorder

Alldredge BK. AHRQ WebM&M [serial online]. May 2007.

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