AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (28)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (30)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (68)

•Medical Complications (45)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (29)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (6)

Resource Types

•Journal Article (185)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (18)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (92)

•Active Errors (58)

•Latent Errors (21)

•Near Miss (5)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (189)

•Nursing (8)

•Pharmacy (23)

Target Audience

•Health Care Providers (176)

•Health Care Executives and Administrators (201)

•Non-Health Care Professionals (66)

•Patients (8)

Setting of Care

•Hospitals (173)

•Residential Facilities (4)

•Ambulatory Care (24)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 228

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COMMENTARY

Transfusion "Slip".

Kaplan HS. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Environmental Safety in the OR.

Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

STUDY

Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study.

Derkx HP, Rethans JE, Muijtjens AM, et al. BMJ. 2008;337:a1264.

COMMENTARY

ISMP medication error report analysis.

Cohen MC. Hosp Pharm. 2009;44:374-378.

STUDY

Assessing clinical handover between paramedics and the trauma team.

Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Andrianopoulos N, Cameron P. Injury. 2010;36:100-106.

BOOK/REPORT

Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.

Baker M. Manchester, England: NHS North West; February 2007.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

STUDY

Consequences of inadequate sign-out for patient care.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

STUDY

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.

Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-736.

STUDY

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

van Walraven C, Jennings A, Taljaard M, et al. CMAJ. 2011;183:E1067-E1072.

STUDY

The impact of clinically undiagnosed injuries on survival estimates.

Gedeborg R, Thiblin I, Byberg L, Wernroth L, Michaëlsson K. Crit Care Med. 2009;37:449-455.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

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