AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (4)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (17)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (22)

•Medical Complications (12)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (17)

•Transfusion Complications (1)

•Psychological and Social Complications (8)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (3)

Resource Types

•Journal Article (67)

•Legislation/Regulation (7)

•Newspaper/Magazine Article (24)

•Press Release/Announcement (3)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (15)

•Active Errors (12)

•Latent Errors (17)

•Near Miss (1)

Approach to Improving Safety
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Regulation

Clinical Areas

•Medicine (54)

•Nursing (5)

•Pharmacy (10)

Target Audience

•Health Care Providers (90)

•Health Care Executives and Administrators (82)

•Non-Health Care Professionals (75)

•Patients (29)

Setting of Care

•Hospitals (54)

•Psychiatric Facilities (2)

•Residential Facilities (8)

•Ambulatory Care (17)

•Outpatient Surgery (5)

•Patient Transport (1)

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COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Listen to the Family.

Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

OR Peeping.

Mackenzie CF. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

Security Lapse.

Mason D. AHRQ WebM&M [serial online]. September 2004.

COMMENTARY

Care Transitions

Kripalani S. AHRQ WebM&M [serial online]. December 2007.

STUDY

Association between license status and medication errors.

Conroy S. Arch Dis Child. 2011;96:305-306.

COMMENTARY

Language barriers to health care in the United States.

Flores G. N Engl J Med. 2006;355:229-231.

REVIEW

How is medication prescribing ceased? A systematic review.

Ostini R, Jackson C, Hegney D, Tett SE. Med Care. 2011;49:24-36.

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Effective implementation of work-hour limits and systemic improvements.

Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33(suppl 1):19-29.

COMMENTARY

In Conversation with...Dean Schillinger, MD

AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

The Wild West: Patient Safety in Office-Based Anesthesia

Kaushal R, Upadhyayula S, Gaba DM, Leape LL. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Abnormal Volunteer Results

Fernandez CV. AHRQ WebM&M [serial online]. June 2007.

PRESS RELEASE/ANNOUNCEMENT

Patient safety and quality improvement.

Federal Register. February 12, 2008;73:8112-8183.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Disclosure of Adverse Events to Patients.

Veterans Health Administration. Washington DC: Department of Veterans Affairs; October 27, 2005. VHA Directive 2008-02.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

NEWSPAPER/MAGAZINE ARTICLE

USP initiatives for the safe use of medical gases.

Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.

BOOK/REPORT

Health Care Comes Home: The Human Factors.

Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.

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