AHRQ Patient Safety Network

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•Device-related Complications (13)

•Diagnostic Errors (15)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (22)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (52)

•Medical Complications (31)

•Nonsurgical Procedural Complications (5)

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•Asia (4)

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•Journal Article (128)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (22)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

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•Epidemiology of Errors and Adverse Events (47)

•Active Errors (28)

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Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (118)

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Target Audience

•Health Care Providers (116)

•Health Care Executives and Administrators (152)

•Non-Health Care Professionals (64)

•Patients (8)

Setting of Care

•Hospitals (131)

•Residential Facilities (4)

•Ambulatory Care (21)

•Outpatient Surgery (3)

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PENNSYLVANIA LEGISLATION

An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act.

General Assembly of Pennsylvania. SB968 (2007).

STUDY

Exploring the causes of adverse events in hospitals and potential prevention strategies.

Smits M, Zegers M, Groenewegen PP, et al. Qual Saf Health Care. 2010;19:e5.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

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

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

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

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

BOOK/REPORT

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Are we finally getting serious about medical errors?

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

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

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.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

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

STUDY

Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety.

Frankel A, Grillo SP, Pittman M, et al. Health Serv Res. 2008;43:2050-2066.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

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

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

Analysis of staff safety concerns.

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

AUDIOVISUAL

Leadership WalkRound Films.

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

BOOK/REPORT

National Diabetes Inpatient Audit 2011.

Leeds, UK: Health and Social Care Information Centre; 2012.

COMMENTARY

In Conversation with...James L. Reinertsen, MD

Reinertsen JL. AHRQ WebM&M [serial online]. July 2007.

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