AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (31)

•Diagnostic Errors (46)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (74)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (126)

•Medical Complications (26)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (45)

•Transfusion Complications (4)

•Psychological and Social Complications (13)

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•Africa (1)

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•Australia and New Zealand (11)

Resource Types

•Journal Article (291)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newspaper/Magazine Article (37)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (4)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (92)

•Legal and Policy Approaches (51)

•Error Reporting and Analysis (131)

•Communication Improvement (112)

•Human Factors Engineering (94)

•Teamwork (23)

•Specialization of Care (14)

•Logistical Approaches (42)

•Culture of Safety (65)

•Technologic Approaches (75)

•Education and Training (79)

Clinical Areas

•Allied Health Services (5)

•Medicine (287)

•Nursing (50)

•Pharmacy (46)

Target Audience

•Health Care Providers (300)

•Health Care Executives and Administrators (288)

•Non-Health Care Professionals (177)

•Patients (30)

Setting of Care

•Hospitals (263)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (34)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 388

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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.

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

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

COMMENTARY

Double Dosing, by the Rules

Cohen H. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

STUDY

Assessing system failures in operating rooms and intensive care units.

van Beuzekom M, Akerboom SP, Boer F. Qual Saf Health Care. 2007;16:45-50.

COMMENTARY

Where’s the Feeding Tube?

Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

Systems approach and systems engineering applied to health care: improving patient safety and health care delivery.

Ravitz AD, Sapirstein A, Pham JC, Doyle PA. Johns Hopkins APL Tech Dig. 2013;31:354-365.

STUDY

Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.

STUDY

PCA safety data review after clinical decision support and smart pump technology implementation.

Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. J Patient Saf. 2013;9:103-109.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

REVIEW

The high-reliability pediatric intensive care unit.

Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.

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.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

STUDY

Errors of diagnosis in pediatric practice: a multisite survey.

Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.

STUDY

Bridging gaps in handoffs: a continuity of care based approach.

Abraham J, Kannampallil TG, Patel VL. J Biomed Inform. 2012;45:240-254.

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.

COMMENTARY

Look-alike and sound-alike medicines: risks and 'solutions.'

Emmerton LM, Rizk MFS. Int J Clin Pharm. 2012;34:4-8.

STUDY

A system analysis of a suboptimal surgical experience.

Lee RC, Cooke DL, Richards M. Patient Saf Surg. 2009;3:1.

STUDY

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN. Arch Dis Child. 2010;95:286-290.

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