AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (21)

•Identification Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (25)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (84)

•Medical Complications (46)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (21)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (3)

Resource Types

•Journal Article (191)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (25)

•Special or Theme Issue (3)

•Tools/Toolkit (4)

Error Types

•Epidemiology of Errors and Adverse Events (75)

•Active Errors (42)

•Latent Errors (16)

•Near Miss (4)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (168)

•Nursing (13)

•Pharmacy (28)

Target Audience

•Health Care Providers (161)

•Health Care Executives and Administrators (211)

•Non-Health Care Professionals (84)

•Patients (11)

Setting of Care

•Hospitals (174)

•Residential Facilities (5)

•Ambulatory Care (27)

•Outpatient Surgery (5)

1 - 20 of 240

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BOOK/REPORT

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

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

NEWSPAPER/MAGAZINE ARTICLE

Are we finally getting serious about medical errors?

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

STUDY

Analysis of staff safety concerns.

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

STUDY

A safety culture transformation: its effects at a children's hospital.

Peterson TH, Teman SF, Connors RH. J Patient Saf. 2012;8:125-130.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

STUDY

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level.

Smits M, Wagner C, Spreeuwenberg P, van der Wal G, Groenewegen PP. Qual Saf Health Care. 2009;18:292-296.

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

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

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

Hospital discharge documentation and risk of rehospitalisation.

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

BOOK/REPORT

The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.

Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.

AUDIOVISUAL

Leadership WalkRound Films.

London, UK: National Patient Safety Agency, NHS Institute for Innovation and Improvement, The Health Foundation, Patient Safety First; 2009.

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.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

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