AHRQ Patient Safety Network

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Nonsurgical Procedural Complications

•Bedside Procedures (12)

•Cardiology (7)

•Gastroenterology (3)

•Interventional Radiology (10)

•Pulmonary Complications (3)

Origin/Sponsor

•Africa (1)

•Asia (3)

•Australia and New Zealand (1)

•Central and South America (1)

Resource Types

•Journal Article (101)

•Legislation/Regulation (7)

•Newspaper/Magazine Article (16)

•Press Release/Announcement (3)

•Special or Theme Issue (1)

•Tools/Toolkit (2)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (35)

•Latent Errors (13)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (46)

•Legal and Policy Approaches (14)

•Error Reporting and Analysis (36)

•Communication Improvement (20)

•Human Factors Engineering (27)

•Teamwork (18)

•Specialization of Care (10)

•Logistical Approaches (4)

•Culture of Safety (20)

•Technologic Approaches (5)

•Education and Training (41)

Clinical Areas

•Allied Health Services (1)

•Medicine (128)

•Nursing (13)

Target Audience

•Health Care Providers (115)

•Health Care Executives and Administrators (113)

•Non-Health Care Professionals (42)

•Patients (15)

Setting of Care

•Hospitals (102)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (14)

•Outpatient Surgery (6)

•Patient Transport (2)

1 - 20 of 141

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COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

COMMENTARY

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

COMMENTARY

A system-wide initiative to prevent retained vaginal sponges.

Chagolla BA, Gibbs VC, Keats JP, Pelletreau B. MCN Am J Matern Child Nurs. 2011;36:312-317.

COMMENTARY

A simple checklist for preventing major complications associated with cesarean delivery.

Duff P. Obstet Gynecol. 2010;116:1393-1396.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

ORGANIZATIONAL POLICY/GUIDELINES

Safety considerations for IMRT.

Moran JM, Dempsey M, Eisbruch A, et al. Pract Radiat Oncol. 2011;1(suppl 1):1-33.

COMMENTARY

Improving patient safety in radiation oncology.

Hendee WR, Herman MG. Med Phys. 2011;38:78-82.

NEWSPAPER/MAGAZINE ARTICLE

Applying the Universal Protocol to improve patient safety in radiology services.

PA-PSRS Patient Saf Advis. June 2011;8:63-69.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

Bogdanich W. New York Times. January 24, 2010:A1.

NEWSPAPER/MAGAZINE ARTICLE

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

STUDY

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.

Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.

COMMENTARY

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

COMMENTARY

Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system.

Deering S, Rosen MA, Salas E, King HB. Simul Healthc. 2009;4:166-173.

REVIEW

Simulation in obstetric anesthesia.

Pratt SD. Anesth Analg. 2012;114:186-190.

STUDY

Unintended exposure in radiotherapy: identification of prominent causes.

Boadu M, Rehani MM. Radiother Oncol. 2009;93:609-617.

REVIEW

The case for simulation as part of a comprehensive patient safety program.

Argani CH, Eichelberger M, Deering S, Satin AJ. Am J Obstet Gynecol. 2012;206:451-455.

STUDY

Effect of computerized physician order entry on radiologic examination order indication quality.

Schneider E, Franz W, Spitznagel R, Bascom DA, Obuchowski NA. Arch Intern Med. 2011;171:1036-1038.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

STUDY

A comprehensive obstetrics patient safety program improves safety climate and culture.

Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-e6.

STUDY

Patient risk factors for medical injury: a case–control study.

Marbella AM, Laud PW, Brasel KJ, Layde PM. BMJ Qual Saf. 2011;20:187-193.

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