AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (14)

•Diagnostic Errors (25)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (27)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (79)

•Medical Complications (43)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (27)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

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•Asia (11)

•Australia and New Zealand (7)

Resource Types

•Journal Article (193)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (12)

•Special or Theme Issue (1)

•Tools/Toolkit (4)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (106)

•Active Errors (62)

•Latent Errors (21)

•Near Miss (5)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (174)

•Nursing (9)

•Pharmacy (25)

Target Audience

•Health Care Providers (181)

•Health Care Executives and Administrators (197)

•Non-Health Care Professionals (67)

•Patients (8)

Setting of Care

•Hospitals (165)

•Residential Facilities (2)

•Ambulatory Care (26)

•Outpatient Surgery (4)

•Patient Transport (1)

1 - 20 of 221

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STUDY

Error tracking in a clinical biochemistry laboratory.

Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Wrong-site sinus surgery in otolaryngology.

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

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.

STUDY

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.

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.

COMMENTARY

Do Not Disturb!

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

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

STUDY

A prevalence study of errors in opioid prescribing in a large teaching hospital.

Davies ED, Schneider F, Childs S, et al. Int J Clin Pract. 2011;65:923-929.

STUDY

Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.

Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.

STUDY

Do emergency physicians attribute drug-related emergency department visits to medication-related problems?

Hohl CM, Zed PJ, Brubacher JR, Abu-Laban RB, Loewen PS, Purssell RA. Ann Emerg Med. 2010;55:493-502.e4.

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.

STUDY

Dispensing errors and counseling quality in 100 pharmacies.

Flynn EA, Barker KN, Berger BA, Lloyd KB, Brackett PD. J Am Pharm Assoc. 2009;49:171-180.

STUDY

Factors associated with medication errors in the pediatric emergency department.

Vilà-de-Muga M, Colom-Ferrer L, Gonzàlez-Herrero M, Luaces-Cubells C. Pediatr Emerg Care. 2011;27:290-294.

COMMENTARY

Crossing the Line.

Feldman JP, Gould MK. AHRQ WebM&M [serial online]. March 2004.

REVIEW

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.

COMMENTARY

Environmental Safety in the OR.

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

STUDY

Patient record review of the incidence, consequences, and causes of diagnostic adverse events.

Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.

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