AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
The Role of the Patient in Safety

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (35)

•Identification Errors (28)

•Discontinuities, Gaps, and Hand-Off Problems (96)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (160)

•Medical Complications (41)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (40)

•Transfusion Complications (1)

•Psychological and Social Complications (53)

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•Australia and New Zealand (16)

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•Audiovisual (17)

•Book/Report (54)

•Journal Article (323)

•Legislation/Regulation (7)

•Meeting/Conference (4)

•Newspaper/Magazine Article (107)

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•Special or Theme Issue (6)

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Error Types

•Epidemiology of Errors and Adverse Events (58)

•Active Errors (100)

•Latent Errors (36)

•Near Miss (10)

Approach to Improving Safety
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Provider-Patient Communication

•Informed Consent (23)

•Health Literacy Improvement (103)

Clinical Areas

•Allied Health Services (2)

•Medicine (323)

•Nursing (23)

•Pharmacy (74)

Target Audience

•Health Care Providers (419)

•Health Care Executives and Administrators (318)

•Non-Health Care Professionals (142)

•Patients (169)

Setting of Care

•Hospitals (243)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (116)

•Outpatient Surgery (7)

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SPECIAL OR THEME ISSUE

Improving Health Care Quality.

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

NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

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.

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

Strategies for improving family engagement during family-centered rounds.

Kelly MM, Xie A, Carayon P, DuBenske LL, Ehlenbach ML, Cox ED. J Hosp Med. 2013;8:201-207.

NEWSPAPER/MAGAZINE ARTICLE

10 things your hospital won't tell you.

Kapadia R. Smart Money. October 2006;15:112-114.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals boost patients' power as advisers.

Landro L. Wall Street Journal. August 8, 2007:D1.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

COMMENTARY

As she lay dying: how I fought to stop medical errors from killing my mom.

Welch JR. Health Aff (Millwood). 2012;31:2817-2820.

NEWSPAPER/MAGAZINE ARTICLE

Parents asking hospital for answers in death of infant.

News 3 Las Vegas (KVBC/DT). December 7, 2006.

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.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #320: partnering with patients to improve safety.

ACOG Committee on Quality Improvement and Patient Safety. Obstet Gynecol. 2005;106:1123-1125.

NEWSPAPER/MAGAZINE ARTICLE

Q: What scares doctors? A: Being the patient.

Gibbs N, Bower A. Time Magazine. May 1, 2006.

STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

NEWSPAPER/MAGAZINE ARTICLE

The best medical care in the U.S.

Arnst C. Business Week. July 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

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.

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