AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (1)

•Medication Safety (10)

•Medical Complications (8)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (4)

•Psychological and Social Complications (2)

Origin/Sponsor

•Australia and New Zealand (1)

•Europe (5)

•North America (29)

Resource Types

•Book/Report (4)

•Journal Article (17)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (4)

•Press Release/Announcement (6)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (7)

•Active Errors (6)

•Latent Errors (1)

Approach to Improving Safety

•Quality Improvement Strategies (10)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (13)

•Communication Improvement (2)

•Human Factors Engineering (3)

•Teamwork (2)

•Culture of Safety (8)

•Technologic Approaches (1)

•Education and Training (5)

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Public Health

Target Audience

•Health Care Providers (26)

•Health Care Executives and Administrators (23)

•Non-Health Care Professionals (21)

•Patients (12)

Setting of Care

•Hospitals (12)

•Residential Facilities (1)

•Ambulatory Care (3)

•Outpatient Surgery (3)

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MULTI-USE WEBSITE

PreventInfection.org.

Association for Professionals in Infection Control and Epidemiology.

BOOK/REPORT

Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.

Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.

COMMENTARY

In Conversation with...James P. Bagian, MD

AHRQ WebM&M [serial online]. September 2006.

COMMENTARY

In Conversation with...Sir Liam Donaldson, MD, MSc

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

COMMENTARY

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Screenings for staph are now the law: state first to apply mandatory testing.

Graham J. Chicago Tribune. August 21, 2007;Metro section:1.

COMMENTARY

The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

Leary E, Diers D. Yale J Biol Med. 2013;86:79-87.

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes no longer billable: bold steps taken by state to reduce hospital errors.

Smith S. Boston Globe. June 19, 2008;Metro section:1B

BOOK/REPORT

Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).

Farley DO, Morton SC, Damberg CL, et al. Santa Monica, CA: The Rand Corporation; 2007. ISBN: 9780833041487.

STUDY

Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study.

Kac G, Podglajen I, Gueneret M, Vaupré S, Bissery A, Meyer G. J Hosp Infect. 2005;60:32-39.

PRESS RELEASE/ANNOUNCEMENT

Shelhigh, Inc. implantable medical devices.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; April 18, 2007.

STUDY

Public perceptions and preferences for patient notification after an unsafe injection.

Schneider AK, Brinsley-Rainisch KJ, Schaefer MK, Camilli T, Perz JF, Cochran RL. J Patient Saf. 2013;9:8-12.

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

STUDY

Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.

Moore TJ, Cohen MR, Furberg CD. Arch Intern Med. 2007;167:1752-1759.

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

Wisc Med J. 2006:105;1-86.

COMMENTARY

Sidelining safety — the FDA's inadequate response to the IOM.

Smith SW. N Engl J Med. 2007;10:960-963.

PRESS RELEASE/ANNOUNCEMENT

Public Health Notification from FDA: Vail Products Enclosed Bed Systems.

Schultz DG. Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration. December 4, 2007.

MULTI-USE WEBSITE

The National Report Card on the State of Emergency Medicine.

Dallas, TX: American College of Emergency Physicians.

PRESS RELEASE/ANNOUNCEMENT

FDA public health notification: unretrieved device fragments.

Schultz DG. Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; January 15, 2008.

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