AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (37)

•Diagnostic Errors (48)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (134)

•Medical Complications (33)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (47)

•Transfusion Complications (4)

•Psychological and Social Complications (15)

Origin/Sponsor

•Australia and New Zealand (10)

•North America (318)

Resource Types

•Audiovisual (5)

•Book/Report (28)

•Clinical Guideline (1)

•Journal Article (304)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newspaper/Magazine Article (60)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (5)

•Web Resource (9)

Error Types
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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (107)

•Legal and Policy Approaches (67)

•Error Reporting and Analysis (139)

•Communication Improvement (125)

•Human Factors Engineering (104)

•Teamwork (24)

•Specialization of Care (17)

•Logistical Approaches (54)

•Culture of Safety (73)

•Technologic Approaches (85)

•Education and Training (85)

Clinical Areas

•Allied Health Services (5)

•Medicine (309)

•Nursing (61)

•Pharmacy (53)

Target Audience

•Health Care Providers (311)

•Health Care Executives and Administrators (313)

•Non-Health Care Professionals (192)

•Patients (46)

Setting of Care

•Hospitals (306)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (39)

•Outpatient Surgery (5)

•Patient Transport (4)

1 - 20 of 435

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STUDY

Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database.

Andersen PO, Maaløe R, Andersen HB. Resuscitation. 2010;81:312-316.

COMMENTARY

Flying Object Hits MRI.

Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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.

STUDY

Mortality related to anaesthesia in France: analysis of deaths related to airway complications.

Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Anaesthesia. 2009;64:366-370.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

STUDY

classic

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

COMMENTARY

Code Blue—Where To?

Adams BD. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

COMMENTARY

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.

COMMENTARY

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

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

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

COMMENTARY classic

classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

NEWSPAPER/MAGAZINE ARTICLE

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

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