AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (26)

•Identification Errors (67)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (25)

•Medication Safety (66)

•Medical Complications (66)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (611)

•Transfusion Complications (3)

•Psychological and Social Complications (34)

Origin/Sponsor

•Africa (2)

•Asia (12)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (604)

•Legislation/Regulation (8)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (85)

•Press Release/Announcement (3)

•Special or Theme Issue (9)

•Tools/Toolkit (9)

•Web Resource (18)

Error Types

•Epidemiology of Errors and Adverse Events (220)

•Active Errors (160)

•Latent Errors (55)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (173)

•Legal and Policy Approaches (55)

•Error Reporting and Analysis (222)

•Communication Improvement (240)

•Human Factors Engineering (174)

•Teamwork (134)

•Specialization of Care (26)

•Logistical Approaches (50)

•Culture of Safety (91)

•Technologic Approaches (77)

•Education and Training (188)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (22)

•General Surgery (32)

•Neurosurgery (14)

•Otolaryngology (10)

•Orthopedic Surgery (21)

•Pediatric Surgery (31)

•Plastic Surgery (12)

•Surgical Oncology (10)

•Urology (6)

•Vascular Surgery (8)

Target Audience

•Health Care Providers (572)

•Health Care Executives and Administrators (553)

•Non-Health Care Professionals (235)

•Patients (79)

Setting of Care

•Hospitals (674)

•Residential Facilities (1)

•Ambulatory Care (16)

•Outpatient Surgery (49)

•Patient Transport (3)

1 - 20 of 768

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BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

MULTI-USE WEBSITE

Standardization Projects.

Washington State Hospital Association.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Check the Wristband.

Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

BOOK/REPORT

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.

NEWSPAPER/MAGAZINE ARTICLE

Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.

PA-PSRS Patient Saf Advis. September 2011;8:85-93.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

COMMENTARY

What Was in Those Platelets?

Yomtovian R. AHRQ WebM&M [serial online]. July 2008.

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

STUDY

Variations in surgical outcomes associated with hospital compliance with safety practices.

Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM. Surgery. 2012;151:651-659.

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

STUDY

The $17.1 billion problem: the annual cost of measurable medical errors.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.

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