AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (17)

•Diagnostic Errors (29)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (28)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (84)

•Medical Complications (48)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (26)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

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•Asia (11)

•Australia and New Zealand (6)

•Central and South America (1)

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•Journal Article (213)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (22)

•Special or Theme Issue (3)

•Tools/Toolkit (4)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (106)

•Active Errors (60)

•Latent Errors (21)

•Near Miss (5)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (196)

•Nursing (9)

•Pharmacy (25)

Target Audience

•Health Care Providers (184)

•Health Care Executives and Administrators (231)

•Non-Health Care Professionals (86)

•Patients (9)

Setting of Care

•Hospitals (190)

•Residential Facilities (4)

•Ambulatory Care (26)

•Outpatient Surgery (5)

•Patient Transport (1)

1 - 20 of 259

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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

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

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

Calligaris L, Panzera A, Arnoldo L, et al. BMC Clin Pharmacol. 2009;9:9.

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

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

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.

STUDY

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.

STUDY

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.

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.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

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.

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

Development of a core drug list towards improving prescribing education and reducing errors in the UK.

Baker E, Roberts AP, Wilde K, et al. Br J Clin Pharmacol. 2011;71:190-198.

STUDY

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

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

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.

BOOK/REPORT

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

Washington, DC: United States Government Accountability Office; October 28, 2011. Publication GAO-12-6R.

STUDY

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.

Balla U, Malnick S, Schattner A. Medicine (Baltimore). 2008;87:294-300.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

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

STUDY

Using prospective clinical surveillance to identify adverse events in hospital.

Forster AJ, Worthington JR, Hawken S, et al. BMJ Qual Saf. 2011;20:756-763.

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