AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (20)

•Diagnostic Errors (48)

•Identification Errors (53)

•Discontinuities, Gaps, and Hand-Off Problems (356)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (312)

•Medical Complications (57)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (153)

•Transfusion Complications (2)

•Psychological and Social Complications (53)

Origin/Sponsor

•Australia and New Zealand (24)

•Europe (107)

•North America (752)

Resource Types

•Audiovisual (10)

•Book/Report (33)

•Clinical Guideline (1)

•Journal Article (691)

•Legislation/Regulation (14)

•Meeting/Conference (4)

•Newspaper/Magazine Article (122)

•Press Release/Announcement (1)

•Special or Theme Issue (18)

•Tools/Toolkit (16)

•Web Resource (15)

Error Types

•Epidemiology of Errors and Adverse Events (160)

•Active Errors (185)

•Latent Errors (88)

•Near Miss (17)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (74)

•Structured Hand-offs (121)

•Medication Reconciliation (189)

Clinical Areas

•Allied Health Services (4)

•Medicine (706)

•Nursing (100)

•Pharmacy (136)

Target Audience

•Health Care Providers (733)

•Health Care Executives and Administrators (706)

•Non-Health Care Professionals (310)

•Patients (59)

Setting of Care

•Hospitals (671)

•Psychiatric Facilities (3)

•Residential Facilities (24)

•Ambulatory Care (100)

•Outpatient Surgery (10)

•Patient Transport (13)

1 - 20 of 928

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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

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.

STUDY

Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture.

Öhrn A, Rutberg H, Nilsen P. J Patient Saf. 2011;7:185-192.

STUDY

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial.

Graumlich JF, Novotny NL, Nace GS, et al. J Hosp Med. 2009;4:E11-E19.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.

Collins TR. The Hospitalist. July 2011.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

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

STUDY

classic

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

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.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

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.

COMMENTARY

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.

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.

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