AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (17)

•Diagnostic Errors (31)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (31)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (98)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (29)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

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•Asia (11)

•Australia and New Zealand (7)

Resource Types

•Journal Article (238)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (26)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (106)

•Active Errors (64)

•Latent Errors (21)

•Near Miss (5)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (207)

•Nursing (14)

•Pharmacy (32)

Target Audience

•Health Care Providers (201)

•Health Care Executives and Administrators (253)

•Non-Health Care Professionals (96)

•Patients (11)

Setting of Care

•Hospitals (211)

•Residential Facilities (4)

•Ambulatory Care (29)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 289

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STUDY

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

STUDY

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.

STUDY

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

STUDY

Analysis of staff safety concerns.

Davidson J, Lamontagne G, Burnell L, et al. J Nurs Care Qual. 2013;28:147-152.

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

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

COMMENTARY

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. Jt Comm J Qual Patient Saf. 2006;32:299-308.

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

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

NEWSPAPER/MAGAZINE ARTICLE

Are we finally getting serious about medical errors?

Burns J. Managed Care Magazine. May 2011;20:23-28.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

STUDY

Physician implicit review to identify preventable errors during in-hospital cardiac arrest.

Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.

COMMENTARY

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

Lubomski LH, Marsteller JA, Hsu YJ, et al. Jt Comm J Qual Patient Saf. 2008;34:619-623.

STUDY

The objective impact of clinical peer review on hospital quality and safety.

Edwards MT. Am J Med Qual. 2011;26:110-119.

BOOK/REPORT

Pulse Report 2009: Safety Culture: Staff Perspectives on American Health Care.

South Bend, IN: Press Ganey Associates, Inc: 2009.

STUDY

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).

Schleyer AM, Best JA, McIntyre LK, Ehrmantraut R, Calver P, Goss JR. Am J Med Qual. 2013;28:243-249.

COMMENTARY

Development and evaluation of the Institute for Healthcare Improvement global trigger tool.

Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. J Patient Saf. 2008;4:169-177.

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