AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (26)

•Identification Errors (72)

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

•Fatigue and Sleep Deprivation (27)

•Medication Safety (71)

•Medical Complications (67)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (600)

•Transfusion Complications (3)

•Psychological and Social Complications (34)

Origin/Sponsor

•Africa (2)

•Asia (10)

•Australia and New Zealand (15)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (616)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (81)

•Press Release/Announcement (2)

•Special or Theme Issue (9)

•Tools/Toolkit (10)

•Web Resource (17)

Error Types

•Epidemiology of Errors and Adverse Events (228)

•Active Errors (151)

•Latent Errors (47)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (189)

•Legal and Policy Approaches (57)

•Error Reporting and Analysis (219)

•Communication Improvement (229)

•Human Factors Engineering (171)

•Teamwork (120)

•Specialization of Care (29)

•Logistical Approaches (56)

•Culture of Safety (96)

•Technologic Approaches (82)

•Education and Training (184)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (25)

•General Surgery (31)

•Neurosurgery (14)

•Otolaryngology (12)

•Orthopedic Surgery (23)

•Pediatric Surgery (30)

•Plastic Surgery (10)

•Surgical Oncology (11)

•Urology (5)

•Vascular Surgery (6)

Target Audience

•Health Care Providers (589)

•Health Care Executives and Administrators (564)

•Non-Health Care Professionals (227)

•Patients (78)

Setting of Care

•Hospitals (679)

•Residential Facilities (2)

•Ambulatory Care (15)

•Outpatient Surgery (45)

•Patient Transport (3)

1 - 20 of 782

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COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

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.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

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.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

STUDY

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

Nakayama DK, Lester SS, Rich DR, Weidner BC, Glenn JB, Shaker IJ. J Pediatr Surg. 2012;47:112-118.

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.

STUDY

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. Ann Surg. 2013;257:1-5.

BOOK/REPORT

National Healthcare Quality Reports.

Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0002.

COMMENTARY

Creating high reliability: a new approach for patient safety.

McGinnis L. AORN J. 2011;94:219-222.

STUDY

Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk or reduced quality of care?

Marang-van de Mheen PJ, van Duijn-Bakker N, Kievit J. Qual Saf Health Care. 2007;16:428-433.

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.

STUDY

Prolonged hospital stay and the resident duty hour rules of 2003.

Silber JH, Rosenbaum PR, Rosen AK, et al. Med Care. 2009;47:1191-1200.

STUDY

Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents.

McCormick F, Kadzielski J, Landrigan CP, Evans B, Herndon JH, Rubash HE. Arch Surg. 2012;147:430-435.

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.

REVIEW

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.

STUDY

The simulated ward: ideal for training clinical clerks in an era of patient safety.

Mollo EA, Reinke CE, Nelson C, et al. J Surg Res. 2012;177:E1-E6.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

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