AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (22)

•Diagnostic Errors (47)

•Identification Errors (59)

•Discontinuities, Gaps, and Hand-Off Problems (368)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (310)

•Medical Complications (60)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (180)

•Transfusion Complications (2)

•Psychological and Social Complications (56)

Origin/Sponsor

•Australia and New Zealand (28)

•Europe (131)

•North America (763)

Resource Types

•Audiovisual (7)

•Book/Report (34)

•Clinical Guideline (2)

•Journal Article (741)

•Legislation/Regulation (15)

•Meeting/Conference (4)

•Newspaper/Magazine Article (124)

•Press Release/Announcement (1)

•Special or Theme Issue (18)

•Tools/Toolkit (13)

•Web Resource (14)

Error Types

•Epidemiology of Errors and Adverse Events (168)

•Active Errors (206)

•Latent Errors (93)

•Near Miss (20)

Approach to Improving Safety
< All

Communication between Providers

•Read Back Protocols (90)

•Structured Hand-offs (139)

•Medication Reconciliation (179)

Clinical Areas

•Allied Health Services (4)

•Dentistry (1)

•Medicine (746)

•Nursing (113)

•Pharmacy (135)

Target Audience

•Health Care Providers (776)

•Health Care Executives and Administrators (749)

•Non-Health Care Professionals (321)

•Patients (52)

Setting of Care

•Hospitals (724)

•Psychiatric Facilities (3)

•Residential Facilities (23)

•Ambulatory Care (102)

•Outpatient Surgery (12)

•Patient Transport (14)

1 - 20 of 977

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AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

STUDY

classic

Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.

Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-1006.

STUDY

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.

Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

BOOK/REPORT classic

classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

STUDY

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

Peer support: healthcare professionals supporting each other after adverse medical events.

van Pelt F. Qual Saf Health Care. 2008;17:249-252.

STUDY

A review of verbal order policies in acute care hospitals.

Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

Patient safety climate in primary care: age matters.

Holden LM, Watts DD, Hinton WP. J Patient Saf. 2009;5:23-28.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

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