AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (15)

•Diagnostic Errors (31)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (30)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (99)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (32)

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•Asia (11)

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•Journal Article (238)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (26)

•Special or Theme Issue (3)

•Tools/Toolkit (6)

•Web Resource (1)

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•Epidemiology of Errors and Adverse Events (100)

•Active Errors (64)

•Latent Errors (21)

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Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (208)

•Nursing (16)

•Pharmacy (34)

Target Audience

•Health Care Providers (198)

•Health Care Executives and Administrators (256)

•Non-Health Care Professionals (97)

•Patients (11)

Setting of Care

•Hospitals (204)

•Residential Facilities (6)

•Ambulatory Care (30)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 291

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STUDY

Hospital discharge documentation and risk of rehospitalisation.

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

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.

STUDY

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

O'Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. J Gen Intern Med. 2010;25:826-832.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

ORGANIZATIONAL POLICY/GUIDELINES

Using medication reconciliation to prevent errors.

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

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

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

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.

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

Electronic health records and adverse drug events after patient transfer.

Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.

STUDY

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

Callen J, McIntosh J, Li J. Int J Med Inform. 2010;79:58-64.

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

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

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

Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists.

Mittal VS, Sigrest T, Ottolini MC, et al. Pediatrics. 2010;126:37-43.

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

How often do physicians review medication charts on ward rounds?

Looi KL, Black PN. BMC Clin Pharmacol. 2008;8:9.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

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

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

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.

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