AHRQ Patient Safety Network

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Nonsurgical Procedural Complications

•Bedside Procedures (7)

•Cardiology (1)

•Interventional Radiology (5)

•Pulmonary Complications (2)

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•Australia and New Zealand (2)

Resource Types

•Journal Article (60)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (8)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (14)

•Active Errors (19)

•Latent Errors (6)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (28)

•Legal and Policy Approaches (7)

•Error Reporting and Analysis (26)

•Communication Improvement (17)

•Human Factors Engineering (16)

•Teamwork (13)

•Specialization of Care (6)

•Logistical Approaches (2)

•Culture of Safety (21)

•Technologic Approaches (3)

•Education and Training (26)

Clinical Areas

•Medicine (72)

•Nursing (8)

Target Audience

•Health Care Providers (71)

•Health Care Executives and Administrators (68)

•Non-Health Care Professionals (27)

•Patients (8)

Setting of Care

•Hospitals (61)

•Psychiatric Facilities (1)

•Ambulatory Care (7)

•Outpatient Surgery (4)

•Patient Transport (1)

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AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

BOOK/REPORT classic

Safe Practices for Better Healthcare—2010 Update.

National Quality Forum. Washington, DC: National Quality Forum; 2010.

BOOK/REPORT

Pediatric Patient Safety in the Emergency Department.

Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

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.

REVIEW

Overview of progress on patient safety.

Pronovost PJ, Holzmueller CG, Ennen CS, Fox HE. Am J Obstet Gynecol. 2011;204:5-10.

STUDY

Supporting structures for team situation awareness and decision making: insights from four delivery suites.

Mackintosh N, Berridge EJ, Freeth D. J Eval Clin Pract. 2009;15:46-54.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.

REVIEW

Perinatal high reliability.

Knox GE, Simpson KR. Am J Obstet Gynecol. 2011;204: 373-377.

REVIEW

Office-based anesthesia.

Kurrek MM, Twersky RS. Can J Anaesth. 2010;57:256-272.

NEWSPAPER/MAGAZINE ARTICLE

Settlement to be used for hospital training in labeling medicines.

Ostrom CM. Seattle Times. September 13, 2005;Local News:B3

BOOK/REPORT

A Patient Safety Handbook for Ambulatory Care Providers.

Oak Brook, IL: Joint Commission Resources; 2009. ISBN: 9781599403670.

BOOK/REPORT

Consumer Guide to Adverse Health Events.

St. Paul, MN: Minnesota Department of Health; January 2009.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

REVIEW

Changing practice to improve patient safety and quality of care in perinatal medicine.

Kaplan HC, Ballard J. Am J Perinatol. 2012;29:35-42.

STUDY

Airway carts: a systems-based approach to airway safety.

Kane BG, Bond WF, Worrilow CC, Richardson DM, on behalf of the Lehigh Valley Hospital Airway Task Force. J Patient Saf. 2006;2:154-161.

STUDY

Risks of complications by attending physicians after performing nighttime procedures.

Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

The use of human factors methods to identify and mitigate safety issues in radiation therapy.

Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA. Radiother Oncol. 2010;97:596-600.

STUDY

Iatrogenic events contributing to ICU admission: a prospective study.

Mercier E, Giraudeau B, Giniès G, Perrotin D, Dequin PF. Intensive Care Med. 2010;36:1033-1037.

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