AHRQ Patient Safety Network

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Device-related Complications

•Indwelling Tubes and Catheters (16)

•Infusion Pumps (19)

•Prostheses and Implants (1)

•Restraints (1)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (3)

Resource Types

•Journal Article (72)

•Legislation/Regulation (6)

•Newspaper/Magazine Article (23)

•Press Release/Announcement (5)

•Special or Theme Issue (1)

•Web Resource (1)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (16)

•Active Errors (31)

•Latent Errors (22)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (37)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (32)

•Communication Improvement (10)

•Human Factors Engineering (86)

•Teamwork (5)

•Specialization of Care (1)

•Logistical Approaches (3)

•Culture of Safety (7)

•Technologic Approaches (15)

•Education and Training (28)

Clinical Areas

•Allied Health Services (2)

•Medicine (78)

•Nursing (10)

•Pharmacy (5)

Target Audience

•Health Care Providers (81)

•Health Care Executives and Administrators (87)

•Non-Health Care Professionals (68)

•Patients (15)

Setting of Care

•Hospitals (74)

•Residential Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (1)

1 - 20 of 116

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COMMENTARY

Procedural Mishap: Learning Curve?

Gibbs VC, Leape LL. AHRQ WebM&M [serial online]. February 2003.

COMMENTARY

Impatient Inpatient Dosing

White RH. AHRQ WebM&M [serial online]. July/August 2005.

COMMENTARY

Secured But Not Always Safe

Jahr JS, Hosseini P. AHRQ WebM&M [serial online]. November 2006.

REVIEW

Retrieval of iatrogenic intravascular foreign bodies.

Schechter MA, O'Brien PJ, Cox MW. J Vasc Surg. 2013;57:276-281.

STUDY

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.

STUDY

Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Qual Saf Health Care. 2010;19:e64.

STUDY

Perioperative patient safety: a multisite qualitative analysis.

Chappy S. AORN J. 2006;83:871-874, 877-888, 891-897.

NEWSPAPER/MAGAZINE ARTICLE

Doctors see flaw in device recalls.

Kerber R. The Boston Globe. June 23, 2005;Business section:E1.

STUDY

Prevention of medical accidents caused by defective surgical instruments.

Yasuhara H, Fukatsu K, Komatsu T, Obayashi T, Saito Y, Uetera Y. Surgery. 2012;151:153-161.

MULTI-USE WEBSITE

Tubing and Luer Misconnections: Preventing Dangerous Medical Errors.

US Food and Drug Administration.

COMMENTARY

Non-Luer connectors: are we nearly there yet?

Cook TM. Anaesthesia. 2012;67:784-792.

REVIEW

Requirements for the design and implementation of checklists for surgical processes.

Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Surg Endosc. 2009;23:715-726.

COMMENTARY

Insert Omission

Darney P. AHRQ WebM&M [serial online]. April 2006.

COMMENTARY

Connectivity to improve patient safety.

Whitehead SF, Goldman JM. Patient Saf Qual Healthcare. January/February 2010;7:26-30.

NEWSPAPER/MAGAZINE ARTICLE

Pharmaceutical industry and medical device companies: part of the solution?

ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.

STUDY

Decisions about critical events in device-related scenarios as a function of expertise.

Laxmisan A, Malhotra S, Keselman A, Johnson TR, Patel VL. J Biomed Inform. 2005;38:200-212.

STUDY

Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency.

Thomas AN, Galvin I. Anaesthesia. 2008;63:1193-1197.

NEWSPAPER/MAGAZINE ARTICLE

ALERT: reports of severe harm after intravenous administration of breast milk to infants.

ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.

COMMENTARY

Implementing AORN recommended practices for laser safety.

Castelluccio D. AORN J. 2012;95:612-627.

AUDIOVISUAL

Software glitches pose new, potentially dangerous problems for medical devices.

Kennedy D. "iHealthBeat." California Healthcare Foundation. July 25, 2008.

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