AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (40)

•Diagnostic Errors (9)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (7)

•Medication Safety (25)

•Medical Complications (130)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (25)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

Origin/Sponsor

•Australia and New Zealand (1)

•Central and South America (1)

•North America (138)

Resource Types

•Audiovisual (4)

•Book/Report (15)

•Clinical Guideline (2)

•Journal Article (103)

•Legislation/Regulation (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (17)

•Press Release/Announcement (6)

•Special or Theme Issue (3)

•Tools/Toolkit (4)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (44)

•Active Errors (31)

•Latent Errors (10)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (84)

•Legal and Policy Approaches (18)

•Error Reporting and Analysis (44)

•Communication Improvement (23)

•Human Factors Engineering (38)

•Teamwork (11)

•Specialization of Care (7)

•Logistical Approaches (7)

•Culture of Safety (22)

•Technologic Approaches (14)

•Education and Training (25)

Clinical Areas
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Infectious Diseases

Target Audience

•Health Care Providers (125)

•Health Care Executives and Administrators (129)

•Non-Health Care Professionals (39)

•Patients (22)

Setting of Care

•Hospitals (132)

•Psychiatric Facilities (1)

•Residential Facilities (4)

•Ambulatory Care (13)

•Outpatient Surgery (5)

1 - 20 of 167

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BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

STUDY

Injection practices among clinicians in United States health care settings.

Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.

MULTI-USE WEBSITE

Solutions for Patient Safety.

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

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

REVIEW

Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.

Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.

COMMENTARY

EMR Entry Error: Not So Benign

Koppel R. AHRQ WebM&M [serial online]. April 2009.

BOOK/REPORT

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

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

NEWSPAPER/MAGAZINE ARTICLE

Shared MDIs: can cross-contamination be avoided?

ISMP Medication Safety Alert! Acute Care Edition. April 9, 2009;14:1-3.

BOOK/REPORT

Report on the Burden of Endemic Health Care–Associated Infection Worldwide.

Allegranzi B, Nejad SB, Castillejos GG, Kilpatrick C, Kelley E, Mathai E; Clean Care is Safer Care Team. Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507.

STUDY

Clinical and economic outcomes attributable to health care–associated sepsis and pneumonia.

Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353.

STUDY

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S. Soc Sci Med. 2010;71:1692-1701.

COMMENTARY

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

BOOK/REPORT classic

classic

The Checklist Manifesto: How to Get Things Right.

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

AUDIOVISUAL

Battling hospital-acquired infections.

Gross T. "Fresh Air." National Public Radio. January 9, 2008.

STUDY

classic

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

Waters HR, Korn R Jr, Colantuoni E, et al. Am J Med Qual. 2011;26:333-339.

STUDY

Infection control assessment of ambulatory surgical centers.

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

COMMENTARY

The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.

Pryor D, Hendrich A, Henkel RJ, Beckmann JK, Tersigni AR. Health Aff (Millwood). 2011;30:604-611.

STUDY

classic

Explaining Michigan: developing an ex post theory of a quality improvement program.

Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Milbank Q. 2011;89:167-205.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

PRESS RELEASE/ANNOUNCEMENT

Relenza (zanamivir) inhalation powder.

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

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