AHRQ Patient Safety Network

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Device-related Complications

•Indwelling Tubes and Catheters (56)

•Infusion Pumps (32)

•Restraints (3)

Origin/Sponsor

•Australia and New Zealand (2)

•North America (194)

Resource Types

•Audiovisual (5)

•Book/Report (9)

•Journal Article (129)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (8)

•Special or Theme Issue (2)

•Tools/Toolkit (2)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (47)

•Active Errors (57)

•Latent Errors (34)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (70)

•Legal and Policy Approaches (24)

•Error Reporting and Analysis (68)

•Communication Improvement (23)

•Human Factors Engineering (104)

•Teamwork (6)

•Specialization of Care (5)

•Logistical Approaches (4)

•Culture of Safety (22)

•Technologic Approaches (32)

•Education and Training (48)

Clinical Areas

•Allied Health Services (3)

•Medicine (155)

•Nursing (19)

•Pharmacy (22)

Target Audience

•Health Care Providers (144)

•Health Care Executives and Administrators (170)

•Non-Health Care Professionals (74)

•Patients (35)

Setting of Care

•Hospitals (164)

•Psychiatric Facilities (1)

•Ambulatory Care (11)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 220

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NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

COMMENTARY

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals tally their avoidable mistakes.

Rein L. Washington Post. July 21, 2009:E1.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

MRI safety 10 years later.

Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.

COMMENTARY

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Jt Comm J Qual Patient Saf. 2010;36:519-524.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

NEWSPAPER/MAGAZINE ARTICLE

Spike in MR imaging accidents underscores need for regulation.

Radiological Society of North America. RSNA News; October 2010.

NEWSPAPER/MAGAZINE ARTICLE

Small patients, big consequences in medical errors.

Tarkan L. New York Times. September 14, 2008;Health section:7.

STUDY

Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.

Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Ann Intern Med. 2012;157:305-312.

AUDIOVISUAL

Notre Dame students design to save lives.

McFadden M. WNDU. February 21, 2012.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

BOOK/REPORT

Serious Reportable Events in Massachusetts Acute Care Hospitals: January 1, 2008–December 31, 2008.

Executive Office of Health and Human Services, Department of Public Health, Bureau of Health Care Safety and Quality. Boston, MA: Commonwealth of Massachusetts; 2009.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

STUDY

A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.

Tran M, Ciarkowski S, Wagner D, Stevenson JG. Jt Comm J Qual Patient Saf. 2012;38:112-119.

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