AHRQ Patient Safety Network

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Nonsurgical Procedural Complications

•Bedside Procedures (8)

•Cardiology (6)

•Gastroenterology (1)

•Interventional Radiology (13)

•Pulmonary Complications (1)

Origin/Sponsor

•Africa (1)

•Asia (3)

•Central and South America (1)

Resource Types

•Journal Article (85)

•Legislation/Regulation (5)

•Newspaper/Magazine Article (11)

•Press Release/Announcement (3)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (19)

•Active Errors (32)

•Latent Errors (14)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (31)

•Communication Improvement (15)

•Human Factors Engineering (24)

•Teamwork (14)

•Specialization of Care (5)

•Logistical Approaches (5)

•Culture of Safety (17)

•Technologic Approaches (6)

•Education and Training (36)

Clinical Areas

•Allied Health Services (1)

•Medicine (105)

•Nursing (11)

Target Audience

•Health Care Providers (90)

•Health Care Executives and Administrators (97)

•Non-Health Care Professionals (38)

•Patients (9)

Setting of Care

•Hospitals (78)

•Psychiatric Facilities (1)

•Ambulatory Care (10)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 114

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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.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

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

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

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.

PRESS RELEASE/ANNOUNCEMENT

CT brain perfusion scans safety investigation: initial notification.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

ORGANIZATIONAL POLICY/GUIDELINES

Preventing maternal death.

Sentinel Event Alert. January 26, 2010;(44):1-4.

MULTI-USE WEBSITE

Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February 2010.

STUDY

An engineered solution to the maladministration of spinal injections.

Lawton R, Gardner P, Green B, et al. Qual Saf Health Care. 2009;18:492-495.

COMMENTARY

Resuscitation Errors: A Shocking Problem

Abella BS, Edelson DP. AHRQ WebM&M [serial online]. July 2007.

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.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

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

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

COMMENTARY

Improving patient safety in radiation oncology.

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

STUDY

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

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

STUDY

Outcomes after out-of-hospital endotracheal intubation errors.

Wang HE, Cook LJ, Chang CC, Yealy DM, Lave JR. Resuscitation. 2009;80:50-55.

ORGANIZATIONAL POLICY/GUIDELINES

ACR guidance document on MR safe practices: 2013.

Kanal E, Barkovich AJ, Bell C, et al; Expert Panel on MR Safety. J Magn Reson Imaging. 2013;37:501-530.

SPECIAL OR THEME ISSUE

Obstetric Issues.

PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.

STUDY

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety.

Simons PAM, Houben RMA, Backes HH, Pijls RFG, Groothuis S. Int J Qual Health Care. 2010;22:187-193.

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