AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (2)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (11)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (33)

•Medical Complications (28)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (30)

•Transfusion Complications (1)

•Psychological and Social Complications (10)

Origin/Sponsor

•Africa (1)

•Asia (1)

•Australia and New Zealand (5)

Resource Types

•Journal Article (123)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (13)

•Special or Theme Issue (5)

•Tools/Toolkit (6)

•Web Resource (12)

Error Types

•Epidemiology of Errors and Adverse Events (30)

•Active Errors (7)

•Latent Errors (3)

Approach to Improving Safety
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Benchmarking

Clinical Areas

Target Audience

•Health Care Providers (89)

•Health Care Executives and Administrators (158)

•Non-Health Care Professionals (88)

•Patients (19)

Setting of Care

•Hospitals (123)

•Residential Facilities (3)

•Ambulatory Care (8)

•Outpatient Surgery (2)

•Patient Transport (1)

1 - 20 of 189

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STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

COMMENTARY

Integrating CUSP and TRIP to improve patient safety.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

Wisc Med J. 2006:105;1-86.

BOOK/REPORT

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

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

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

DATABASE/DIRECTORY

MEDMARX®.

Rockville, MD: U.S. Pharmacopeia; 2011.

STUDY

The safety culture in a children's hospital.

Grant MJC, Donaldson AE, Larsen GY. J Nurs Care Qual. 2006;21:223-229.

BOOK/REPORT

Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.

Davis K, Schoen S, Schoenbaum SC, et al. New York, NY: The Commonwealth Fund; April 2006.

REVIEW

Systematic review: impact of health information technology on quality, efficiency, and costs of medical care.

Chaudhry B, Wang J, Wu S, et al. Ann Intern Med. 2006;144:742-752.

BOOK/REPORT

Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care.

Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.

COMMENTARY

Developing a medication patient safety program, part 2: process and implementation.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:249–254.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

COMMENTARY

Kaiser Permanente's performance improvement system, part 4: creating a learning organization.

Schilling L, Dearing JW, Staley P, Harvey P, Fahey L, Kuruppu F. Jt Comm J Qual Patient Saf. 2011;37:532-543.

STUDY

Hospital patient safety: characteristics of best-performing hospitals.

Longo DR, Hewett JE, Ge B, Schubert S. J Healthc Manag. 2007;52:188-204; discussion 204-205.

NEWSPAPER/MAGAZINE ARTICLE

If safety is your yardstick, measuring culture from the top down must be a priority.

ISMP Medication Safety Alert! Acute Care Edition. March 22, 2007;12:1-2.

STUDY

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

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

STUDY

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

Kaissi A, Kralewski J, Dowd B, Heaton A. Health Care Manage Rev. 2007;32:12-21.

STUDY

Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.

Bognár A, Barach P, Johnson JK, et al. Ann Thorac Surg. 2008;85:1374-1381.

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