AHRQ Patient Safety Network

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Nonsurgical Procedural Complications

•Bedside Procedures (10)

•Cardiology (5)

•Gastroenterology (3)

•Interventional Radiology (13)

•Pulmonary Complications (2)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (2)

•Central and South America (1)

Resource Types

•Journal Article (96)

•Legislation/Regulation (5)

•Newspaper/Magazine Article (17)

•Press Release/Announcement (3)

•Special or Theme Issue (2)

•Tools/Toolkit (2)

Error Types

•Epidemiology of Errors and Adverse Events (25)

•Active Errors (29)

•Latent Errors (10)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (41)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (40)

•Communication Improvement (20)

•Human Factors Engineering (24)

•Teamwork (17)

•Specialization of Care (9)

•Logistical Approaches (5)

•Culture of Safety (21)

•Technologic Approaches (6)

•Education and Training (40)

Clinical Areas

•Allied Health Services (1)

•Medicine (120)

•Nursing (10)

Target Audience

•Health Care Providers (103)

•Health Care Executives and Administrators (114)

•Non-Health Care Professionals (39)

•Patients (14)

Setting of Care

•Hospitals (97)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (11)

•Outpatient Surgery (6)

•Patient Transport (2)

1 - 20 of 134

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STUDY

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

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

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.

STUDY

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

Cravero JP, Blike GT, Beach M, et al. Pediatrics. 2006;118:1087-1096.

STUDY

Paramedic intubation errors: isolated events or symptoms of larger problems?

Wang HE, Lave JR, Sirio CA, Yealy DM. Health Aff (Millwood). 2006;25:501-509.

STUDY

Outcomes after out-of-hospital endotracheal intubation errors.

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

STUDY

Overview of adverse events related to invasive procedures in the intensive care unit.

Pottier V, Daubin C, Lerolle N, et al. Am J Infect Control. 2012;40:241-246.

STUDY

Injury and death associated with incidents reported to the Patient Safety Net.

Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.

STUDY

The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.

Leffler DA, Kheraj R, Garud S, et al. Arch Intern Med. 2010;170:1752-1757.

STUDY

Adverse events after screening and follow-up colonoscopy.

Rutter CM, Johnson E, Miglioretti DL, Mandelson MT, Inadomi J, Buist DSM. Cancer Causes Control. 2012;23:289-296.

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.

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

Improving patient safety in radiation oncology.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

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

Meisel Z. Slate. November 8, 2005.

BOOK/REPORT

A Patient Safety Handbook for Ambulatory Care Providers.

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

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.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing maternal death.

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

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.

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.

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