AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (15)

•Diagnostic Errors (26)

•Identification Errors (8)

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

•Fatigue and Sleep Deprivation (4)

•Medication Safety (90)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (33)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

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•Asia (11)

•Australia and New Zealand (7)

Resource Types

•Journal Article (224)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (22)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (98)

•Active Errors (60)

•Latent Errors (22)

•Near Miss (4)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (196)

•Nursing (14)

•Pharmacy (28)

Target Audience

•Health Care Providers (190)

•Health Care Executives and Administrators (249)

•Non-Health Care Professionals (83)

•Patients (9)

Setting of Care

•Hospitals (204)

•Residential Facilities (6)

•Ambulatory Care (25)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 270

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STUDY

Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.

Longmate AG, Ellis KS, Boyle L, et al. BMJ Qual Saf. 2011;20:174-180.

STUDY

Real time patient safety audits: improving safety every day.

Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.

STUDY

Promoting patient safety using an early warning scoring system.

Higgins Y, Maries-Tillott C, Quinton S, Richmond J. Nurs Stand. 2008;22:35-40.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

STUDY

Audit of handover in an ENT unit.

Ellul D, Robson AK. J Laryngol Otol. 2011;125:924-927.

STUDY

The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events.

van Gaal BG, Schoonhoven L, Hulscher ME, et al. BMC Health Serv Res. 2009;9:58.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D, Dunn E. Am Surg. 2009;75:1171-1174.

BOOK/REPORT

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

Thomson R, Luettel D, Healey F, Scobie S. London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634055.

STUDY

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

Byrnes MC, Schuerer DJ, Schallom ME, et al. Crit Care Med. 2009; 37:2775-2781.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

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

STUDY

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

BOOK/REPORT

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

STUDY

A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures.

Krimsky WS, Mroz IB, McIlwaine JK, et al. Qual Saf Health Care. 2009;18:74-80.

STUDY

Stakeholder challenges in purchasing medical devices for patient safety.

Hinrichs S, Dickerson T, Clarkson J. J Patient Saf. 2013;9:36-43.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

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

STUDY

Using Medical Emergency Teams to detect preventable adverse events.

Iyengar A, Baxter A, Forster AJ. Crit Care. 2009;13:R126.

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