AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (48)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (96)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (155)

•Medical Complications (34)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (52)

•Transfusion Complications (4)

•Psychological and Social Complications (15)

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•Australia and New Zealand (9)

•North America (368)

Resource Types

•Audiovisual (8)

•Book/Report (27)

•Clinical Guideline (1)

•Journal Article (341)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (73)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (5)

•Web Resource (10)

Error Types
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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (113)

•Legal and Policy Approaches (74)

•Error Reporting and Analysis (147)

•Communication Improvement (133)

•Human Factors Engineering (113)

•Teamwork (28)

•Specialization of Care (19)

•Logistical Approaches (61)

•Culture of Safety (80)

•Technologic Approaches (98)

•Education and Training (94)

Clinical Areas

•Allied Health Services (4)

•Medicine (349)

•Nursing (65)

•Pharmacy (63)

Target Audience

•Health Care Providers (340)

•Health Care Executives and Administrators (352)

•Non-Health Care Professionals (217)

•Patients (52)

Setting of Care

•Hospitals (340)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (48)

•Outpatient Surgery (5)

•Patient Transport (4)

1 - 20 of 490

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BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

STUDY

The impact of drug shortages on children with cancer—the example of mechlorethamine.

Metzger ML, Billett A, Link MP. N Engl J Med. 2012;367:2461-2463.

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

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

STUDY

Complexity of medication-related verbal orders.

Wakefield DS, Ward MM, Groath D, et al. Am J Med Qual. 2008;23:7-17.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

COMMENTARY

Medication tracers: a systems approach to medication safety.

Hendrick EC, Montanya KR, Griffith N. Hosp Pharm. 2007;42:916-920.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

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

A multiple-drawer medication layout problem in automated dispensing cabinets.

Pazour JA, Meller RD. Health Care Manag Sci. 2012;15:339-354.

STUDY

Interruption handling strategies during paediatric medication administration.

Colligan L, Bass EJ. BMJ Qual Saf. 2012;21:912-917.

BOOK/REPORT

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

STUDY

Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.

Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. J Acad Nutr Diet. 2012;112:1656-1661.

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.

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

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

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

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

COMMENTARY

Preventable errors in organ transplantation: an emerging patient safety issue?

Ison MG, Holl JL, Ladner D. Am J Transplant. 2012;12:2307-2312.

STUDY

Quantitative assessment of workload and stressors in clinical radiation oncology.

Mazur LM, Mosaly PR, Jackson M, et al. Int J Radiat Oncol Biol Phys. 2012;83:e571-e576.

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.

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