AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Detection of Safety Hazards

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Safety Target

•Device-related Complications (61)

•Diagnostic Errors (95)

•Identification Errors (40)

•Discontinuities, Gaps, and Hand-Off Problems (82)

•Fatigue and Sleep Deprivation (14)

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Error Types

•Epidemiology of Errors and Adverse Events (612)

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Approach to Improving Safety
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Error Reporting and Analysis

•Error Reporting (535)

•Error Analysis (646)

•Patient Safety Indicators (69)

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•Allied Health Services (2)

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Target Audience

•Health Care Providers (856)

•Health Care Executives and Administrators (1119)

•Non-Health Care Professionals (416)

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Setting of Care

•Hospitals (786)

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1 - 20 of 1369

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STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists.

Bauer P, Hoffmann RG, Bragg D, Scanlon MC. Safety Sci. 2013;53:160-167.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

Pediatric safety incidents from an intensive care reporting system.

Skapik JL, Pronovost PJ, Miller MR, Thompson DA, Wu AW. J Patient Saf. 2009;5:95-101.

STUDY

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Adverse drug events in a paediatric intensive care unit: a prospective cohort.

Silva DCB, Araujo OR, Arduini RG, Alonso CFR, Shibata ARO, Troster EJ. BMJ Open. 2013;3:ee001868.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. Crit Care Med. 2013;41:389-398.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Pediatrics. 2005;116:603-608.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Effect of illness severity and comorbidity on patient safety and adverse events.

Naessens J, Campbell CR, Shah N, et al. Am J Med Qual. 2012;27:48-57.

REVIEW

Developing a patient safety surveillance system to identify adverse events in the intensive care unit.

Stockwell DC, Kane-Gill SL. Crit Care Med. 2010;38(suppl 6):S117-S125.

STUDY

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215.

REVIEW

New perspectives on error in critical care.

Patel VL, Cohen T. Curr Opin Crit Care. 2008;14:456-459.

STUDY

Development of the ICU safety reporting system.

Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1:23-32.

REVIEW

Failure mode and effects analysis application to critical care medicine.

Duwe B, Fuchs BD, Hansen-Flaschen J. Crit Care Clin. 2005;21:21-30, vii.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

COMMENTARY

Patient safety in the context of neonatal intensive care: research and educational opportunities.

Raju TN, Suresh G, Higgins RD. Pediatr Res. 2011;70:109-115.

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