AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (24)

•Diagnostic Errors (57)

•Identification Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (57)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (211)

•Medical Complications (55)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (63)

•Transfusion Complications (3)

•Psychological and Social Complications (21)

Origin/Sponsor

•Australia and New Zealand (31)

•Central and South America (3)

•Europe (166)

•North America (415)

Resource Types

•Book/Report (32)

•Journal Article (555)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (36)

•Press Release/Announcement (1)

•Special or Theme Issue (8)

•Tools/Toolkit (6)

•Web Resource (7)

Error Types

•Epidemiology of Errors and Adverse Events (257)

•Active Errors (99)

•Latent Errors (83)

•Near Miss (19)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (48)

•Failure Mode Effects Analysis (31)

•Morbidity and Mortality Conferences (6)

•Narrative/Storytelling (10)

Clinical Areas

•Allied Health Services (1)

•Medicine (438)

•Nursing (79)

•Pharmacy (62)

Target Audience

•Health Care Providers (381)

•Health Care Executives and Administrators (559)

•Non-Health Care Professionals (206)

•Patients (20)

Setting of Care

•Hospitals (433)

•Psychiatric Facilities (3)

•Residential Facilities (10)

•Ambulatory Care (60)

•Outpatient Surgery (3)

•Patient Transport (5)

1 - 20 of 649

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REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

BOOK/REPORT

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.

NEWSPAPER/MAGAZINE ARTICLE

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4.

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

REVIEW

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

Burnett E, Kearney N, Johnston B, Corlett J, Macgillivray S. Am J Infect Control. 2013;41:394-400.

STUDY

Nurses relate the contributing factors involved in medication errors.

Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. J Clin Nurs. 2007;16:447-457.

STUDY

What do hospital staff in the UK think are the causes of penicillin medication errors?

Wilcock M, Harding G, Moore L, Nicholls I, Powell N, Stratton J. Int J Clin Pharm. 2013;35:72-78.

STUDY

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. Ann Surg. 2013;257:1-5.

STUDY

Task uncertainty and communication during nursing shift handovers.

Mayor E, Bangerter A, Aribot M. J Adv Nurs. 2012;68:1956-1966.

STUDY

Decision-making processes used by nurses during intravenous drug preparation and administration.

Dougherty L, Sque M, Crouch R. J Adv Nurs. 2012;68:1302-1311.

STUDY

"Learning by Doing"—resident perspectives on developing competency in high-quality discharge care.

Greysen SR, Schiliro D, Curry L, Bradley EH, Horwitz LI. J Gen Intern Med. 2012;27:1188-1194.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

REVIEW

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.

Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. BMJ Qual Saf. 2012;21:369-380.

STUDY

Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation.

Dooley MJ, Wiseman M, Gu G. Intern Med J. 2012;42:e19-e22.

STUDY

classic

Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.

Hogan H, Healey F, Neale G, Thomson R, Vincent C, Black N. BMJ Qual Saf. 2012;21:737-745.

STUDY

classic

How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.

Hauck K, Zhao X. Med Care. 2011;49:1068-1075.

REVIEW

Interruptions during nurses' work: a state-of-the-science review.

Hopkinson SG, Jennings BM. Res Nurs Health. 2013;36:38-53.

STUDY

How nurses and physicians judge their own quality of care for deteriorating patients on medical wards: self-assessment of quality of care is suboptimal.

Ludikhuize J, Dongelmans DA, Smorenburg SM, Gans-Langelaar M, de Jonge E, de Rooij SE. Crit Care Med. 2012;40:2982–2986.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

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