AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (25)

•Diagnostic Errors (78)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (61)

•Fatigue and Sleep Deprivation (11)

•Medication Safety (277)

•Medical Complications (64)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (76)

•Transfusion Complications (4)

•Psychological and Social Complications (35)

Origin/Sponsor

•Australia and New Zealand (32)

•Central and South America (2)

•Europe (110)

•North America (676)

Resource Types

•Audiovisual (8)

•Book/Report (55)

•Journal Article (690)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (58)

•Press Release/Announcement (4)

•Special or Theme Issue (8)

•Tools/Toolkit (11)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (321)

•Active Errors (111)

•Latent Errors (72)

•Near Miss (24)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (100)

•Failure Mode Effects Analysis (41)

•Morbidity and Mortality Conferences (15)

•Narrative/Storytelling (25)

Clinical Areas

•Allied Health Services (4)

•Dentistry (2)

•Medicine (521)

•Nursing (67)

•Pharmacy (97)

Target Audience

•Health Care Providers (559)

•Health Care Executives and Administrators (673)

•Non-Health Care Professionals (277)

•Patients (52)

Setting of Care

•Hospitals (491)

•Psychiatric Facilities (4)

•Residential Facilities (15)

•Ambulatory Care (78)

•Outpatient Surgery (7)

•Patient Transport (6)

1 - 20 of 855

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

NEWSPAPER/MAGAZINE ARTICLE

Survive your doctor.

Holt TE. Men's Health. November 3, 2006.

COMMENTARY

Ashamed to admit it: owning up to medical error.

Ofri D. Health Aff (Millwood). 2010;29:1549-1551.

DATABASE/DIRECTORY

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

STUDY

Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.

Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, Brem H, Quiñones-Hinojosa A. Arch Surg. 2011;146:226-232.

NEWSPAPER/MAGAZINE ARTICLE

How business intelligence can improve patient safety.

Wanless S, McManaway J. Business Intelligence Network. August 30, 2005.

STUDY

The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

STUDY

Medication safety in a psychiatric hospital.

Rothschild JM, Mann K, Keohane CA, et al. Gen Hosp Psychiatry. 2007;29:156-162.

BOOK/REPORT classic

classic

Preventing Medication Errors: Quality Chasm Series.

Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.

MEASUREMENT TOOL/INDICATOR

2005 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

Huntingdon Valley, PA: Institute for Safe Medication Practices; 2005.

BOOK/REPORT

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

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

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

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

AUDIOVISUAL

Health agency: drug errors still common.

Knox R. "All Things Considered." National Public Radio. July 20, 2006.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

NEWSPAPER/MAGAZINE ARTICLE

Studies on medical errors warrant a second opinion.

Bialik C. The Wall Street Journal Online. June 29, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Report: hospital errors cost 18 lives.

Rojas-Burke J. Oregonian. January 30, 2007:B01.

STUDY

Anticoagulation-associated adverse drug events.

Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.

STUDY

Language proficiency and adverse events in US hospitals: a pilot study.

Divi C, Koss RG, Schmaltz SP, Loeb JM. Int J Qual Health Care. 2007;19:60-67.

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