AHRQ Patient Safety Network

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•Device-related Complications (2)

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•Identification Errors (46)

•Discontinuities, Gaps, and Hand-Off Problems (15)

•Medication Safety (21)

•Medical Complications (2)

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•Surgical Complications (68)

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•Epidemiology of Errors and Adverse Events (15)

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Approach to Improving Safety
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Read Back Protocols

Clinical Areas

Target Audience

•Health Care Providers (82)

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•Non-Health Care Professionals (18)

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Setting of Care

•Hospitals (91)

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1 - 20 of 107

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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.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

NEWSPAPER/MAGAZINE ARTICLE

Five hospitals release data on inspections.

Kowalczyk L. Boston Globe. April 21, 2007:B1.

COMMENTARY

Increasing patient safety and surgical team communication by using a count/time out board.

Edel EM. AORN J. 2010;92:420-424.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

NEWSPAPER/MAGAZINE ARTICLE

Save lives now: five ways to improve patient safety in the ED.

Dunn P. Hosp Health Netw. April 2007;81:42-44,46,48,2.

STUDY

Is the test result correct? A questionnaire study of blood collection practices in primary health care.

Söderberg J, Wallin O, Grankvist K, Brulin C. J Eval Clin Pract. 2010;16:707-711.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

STUDY

Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during medication administration.

Kelly T, Roper C, Elsom S, Gaskin C. Int J Ment Health Nurs. 2011;20:371-379.

NEWSPAPER/MAGAZINE ARTICLE

Commanding safety.

Huff C. Trustee Magazine. October 2011.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: what can medicine learn from aviation?

O'Reilly KB. American Medical News. June 14, 2010.

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

COMMENTARY

Lost in the Black Hole.

Wachter RM. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

Critical laboratory value notification: a failure mode effects and criticality analysis.

Saxena S, Kempf R, Wilcox S, et al. Jt Comm J Qual Patient Saf. 2005;31:495-506.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

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

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

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.

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