AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (27)

•Identification Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (29)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (88)

•Medical Complications (46)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (32)

•Transfusion Complications (1)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (5)

Resource Types

•Journal Article (218)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (22)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (91)

•Active Errors (56)

•Latent Errors (17)

•Near Miss (4)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (190)

•Nursing (13)

•Pharmacy (30)

Target Audience

•Health Care Providers (191)

•Health Care Executives and Administrators (231)

•Non-Health Care Professionals (82)

•Patients (10)

Setting of Care

•Hospitals (191)

•Residential Facilities (3)

•Ambulatory Care (24)

•Outpatient Surgery (5)

•Patient Transport (1)

1 - 20 of 262

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COMMENTARY

Environmental Safety in the OR.

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

STUDY

Patient characteristics and the occurrence of never events.

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

STUDY

Development of trigger tools for surveillance of adverse events in ambulatory surgery.

Kaafarani HM, Rosen AK, Nebeker JR, et al. Qual Saf Health Care. 2010;19:425-429.

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

Wrong-site sinus surgery in otolaryngology.

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

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

STUDY

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. J Am Coll Surg. 2010;211:540-545.

STUDY

Methodology and bias in assessing compliance with a surgical safety checklist.

Poon SJ, Zuckerman SL, Mainthia R, et al. Jt Comm J Qual Patient Saf. 2013;39:77-82.

COMMENTARY

Tracking progress in patient safety: an elusive target.

Pronovost PJ, Miller MR, Wachter RM. JAMA. 2006;296:696-699.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

Analysis of staff safety concerns.

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

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.

BOOK/REPORT

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

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

ORGANIZATIONAL POLICY/GUIDELINES

Using medication reconciliation to prevent errors.

Sentinel Event Alert. January 25, 2006;(35):1-4.

REVIEW

Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.

Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.

STUDY

Family-centered multidisciplinary rounds enhance the team approach in pediatrics.

Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kwoh CK. Pediatrics. 2009;123:e603-e608.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

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