AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (41)

•Diagnostic Errors (39)

•Identification Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (58)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (172)

•Medical Complications (60)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (46)

•Transfusion Complications (1)

•Psychological and Social Complications (10)

Origin/Sponsor

•Australia and New Zealand (11)

•North America (304)

Resource Types

•Audiovisual (2)

•Book/Report (22)

•Clinical Guideline (10)

•Journal Article (222)

•Legislation/Regulation (32)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (58)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (15)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (42)

•Active Errors (77)

•Latent Errors (33)

•Near Miss (5)

Approach to Improving Safety
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Practice Guidelines

Clinical Areas

•Allied Health Services (2)

•Dentistry (2)

•Medicine (268)

•Nursing (37)

•Pharmacy (53)

Target Audience

•Health Care Providers (348)

•Health Care Executives and Administrators (264)

•Non-Health Care Professionals (58)

•Patients (25)

Setting of Care

•Hospitals (223)

•Psychiatric Facilities (5)

•Residential Facilities (6)

•Ambulatory Care (48)

•Outpatient Surgery (7)

•Patient Transport (2)

1 - 20 of 385

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NEWSPAPER/MAGAZINE ARTICLE

Follow-up tips for a safe, efficient practice.

Weiss GG. Med Econ. May 19, 2006; 83:47-49.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

COMMENTARY

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

STUDY

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.

Rask K, Culler S, Scott T, et al. J Hosp Med. 2007;2:212-218.

COMMENTARY

Safe medication prescribing and monitoring in the outpatient setting.

Shojania KG. CMAJ. 2006;174:1257-1258.

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

FACT SHEET/FAQS

Medication safety issue brief. Counterfeit drug prevention and identification.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

SPECIAL OR THEME ISSUE

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

NEWSPAPER/MAGAZINE ARTICLE

Death by handwriting.

Glabman M. Trustee. October 2005;58:29-32.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

BOOK/REPORT classic

classic

Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy.

Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Washington, DC: National Quality Forum; 2005.

STUDY

Delayed or missed diagnosis of cervical spine injuries.

Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. J Trauma. 2006;61:150-155.

ORGANIZATIONAL POLICY/GUIDELINES

Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum.

Nutescu EA, Wittkowsky AK, Burnett A, Merli GJ, Ansell JE, Garcia DA. Ann Pharmacother. 2013;47:714-724.

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.

PRESS RELEASE/ANNOUNCEMENT

Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.

National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System Pharmacists and Institute for Safe Medication Practices; January 23, 2013.

COMMENTARY classic

classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

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