AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (28)

•Diagnostic Errors (25)

•Identification Errors (68)

•Discontinuities, Gaps, and Hand-Off Problems (67)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (61)

•Medical Complications (68)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (633)

•Transfusion Complications (3)

•Psychological and Social Complications (38)

Origin/Sponsor

•Africa (2)

•Asia (8)

•Australia and New Zealand (16)

•Central and South America (1)

Resource Types

•Clinical Guideline (3)

•Journal Article (635)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (88)

•Press Release/Announcement (2)

•Special or Theme Issue (10)

•Tools/Toolkit (12)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (195)

•Active Errors (156)

•Latent Errors (52)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (188)

•Legal and Policy Approaches (61)

•Error Reporting and Analysis (214)

•Communication Improvement (246)

•Human Factors Engineering (178)

•Teamwork (146)

•Specialization of Care (26)

•Logistical Approaches (58)

•Culture of Safety (96)

•Technologic Approaches (78)

•Education and Training (197)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (25)

•General Surgery (41)

•Neurosurgery (13)

•Otolaryngology (12)

•Orthopedic Surgery (21)

•Pediatric Surgery (30)

•Plastic Surgery (15)

•Surgical Oncology (12)

•Urology (6)

•Vascular Surgery (7)

Target Audience

•Health Care Providers (603)

•Health Care Executives and Administrators (572)

•Non-Health Care Professionals (243)

•Patients (86)

Setting of Care

•Hospitals (707)

•Residential Facilities (2)

•Ambulatory Care (18)

•Outpatient Surgery (47)

•Patient Transport (3)

1 - 20 of 811

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BOOK/REPORT

2009 National Healthcare Quality Report.

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

BOOK/REPORT

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

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

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

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.

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.

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.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

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

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.

MULTI-USE WEBSITE

Solutions for Patient Safety.

Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.

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.

STUDY

Association between Leapfrog safe practices score and hospital mortality in major surgery.

Qian F, Lustik SJ, Diachun CA, Wissler RN, Zollo RA, Glance LG. Med Care. 2011;49:1082-1088.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

Frush K. AHRQ WebM&M [serial online]. May 2005.

BOOK/REPORT classic

The Checklist Manifesto: How to Get Things Right.

Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.

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.

COMMENTARY

Staggered Sensitivity Results

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

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