AHRQ Patient Safety Network

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Nonsurgical Procedural Complications

•Bedside Procedures (10)

•Cardiology (4)

•Interventional Radiology (3)

•Pulmonary Complications (4)

Origin/Sponsor

•Africa (1)

•Asia (2)

•Australia and New Zealand (2)

Resource Types

•Journal Article (70)

•Legislation/Regulation (6)

•Newspaper/Magazine Article (12)

•Press Release/Announcement (1)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (14)

•Active Errors (30)

•Latent Errors (10)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (12)

•Error Reporting and Analysis (21)

•Communication Improvement (21)

•Human Factors Engineering (21)

•Teamwork (14)

•Specialization of Care (8)

•Logistical Approaches (3)

•Culture of Safety (16)

•Technologic Approaches (5)

•Education and Training (36)

Clinical Areas

•Medicine (94)

•Nursing (8)

Target Audience

•Health Care Providers (90)

•Health Care Executives and Administrators (74)

•Non-Health Care Professionals (33)

•Patients (11)

Setting of Care

•Hospitals (76)

•Residential Facilities (1)

•Ambulatory Care (9)

•Outpatient Surgery (5)

•Patient Transport (1)

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COMMENTARY

Charcoal Lavage of the Lungs.

Wigton RS. AHRQ WebM&M [serial online]. October 2003.

NEWSPAPER/MAGAZINE ARTICLE

Ding-a-ling-a-ling: ambulances can be dangerous places.

Meisel Z. Slate. November 8, 2005.

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.

COMMENTARY

Compare and Contrast.

Cho KC, Chertow GM. AHRQ WebM&M [serial online]. April 2005.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

Landro L. Wall Street Journal. February 18, 2009:D1.

COMMENTARY

A Little Shuteye.

Farion KJ. AHRQ WebM&M [serial online]. July 2003.

COMMENTARY

Reaction to Dye.

Cohan R. AHRQ WebM&M [serial online]. September 2004.

STUDY

Development and usability of a behavioural marking system for performance assessment of obstetrical teams.

Tregunno D, Pittini R, Haley M, Morgan PJ. Qual Saf Health Care. 2009;18:393-396.

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

Procedural safety in emergency care: a conceptual model and recommendations.

Pines JM, Kelly JJ, Meisl H, et al. Jt Comm J Qual Patient Saf. 2012;38:516-526.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel.

Shavit I, Steiner IP, Idelman S, et al. Acad Emerg Med. 2008;15:617-622.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

COMMENTARY

Danger in Disruption

Fontaine DK. AHRQ WebM&M [serial online]. October 2009.

STUDY

Incidence and prevention of iatrogenic urethral injuries.

Kashefi C, Messer K, Barden R, Sexton C, Parsons JK. J Urol. 2008;179:2254-2257; discussion 2257-2258.

REVIEW

Obstetric medical emergency teams are a step forward in maternal safety!

Al Kadri HM. J Emerg Trauma Shock. 2010;3:337-341.

STUDY

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog J; Pediatric Sedation Research Consortium. Anesth Analg. 2009;108:795-804.

STUDY

Content analysis of team communication in an obstetric emergency scenario.

Siassakos D, Draycott T, Montague I, Harris M. J Obstet Gynaecol. 2009;29:499-503.

BOOK/REPORT

Characteristics of Weekday and Weekend Hospital Admissions, 2007.

Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.

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