AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Human Factors Engineering

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Safety Target

•Device-related Complications (100)

•Diagnostic Errors (29)

•Identification Errors (46)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (306)

•Medical Complications (102)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (142)

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•Psychological and Social Complications (11)

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•Journal Article (494)

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•Meeting/Conference (13)

•Newspaper/Magazine Article (125)

•Press Release/Announcement (12)

•Special or Theme Issue (26)

•Tools/Toolkit (7)

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Error Types

•Epidemiology of Errors and Adverse Events (113)

•Active Errors (193)

•Latent Errors (97)

•Near Miss (17)

Approach to Improving Safety
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Human Factors Engineering

•Forcing Functions (26)

•Medical Device Design (73)

•Medical Alarm Design (31)

•Checklists (152)

•Failure Mode Effects Analysis (7)

Clinical Areas

•Allied Health Services (2)

•Medicine (512)

•Nursing (86)

•Pharmacy (138)

Target Audience

•Health Care Providers (553)

•Health Care Executives and Administrators (598)

•Non-Health Care Professionals (298)

•Patients (54)

Setting of Care

•Hospitals (501)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (56)

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BOOK/REPORT classic

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

COMMENTARY

Learning accountability for patient outcomes.

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

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

Sentinel Event Alert. June 3, 2010;(45):1-3.

STUDY

Practically speaking: rethinking hand hygiene improvement programs in health care settings.

Son C, Chuck T, Childers T, et al. Am J Infect Control. 2011;39:716-724.

NEWSPAPER/MAGAZINE ARTICLE

Are we finally getting serious about medical errors?

Burns J. Managed Care Magazine. May 2011;20:23-28.

BOOK/REPORT classic

Patient Safety in Emergency Medicine.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

STUDY

Using Lean to improve medication administration safety: in search of the "perfect dose."

Ching JM, Long C, Williams BL, Blackmore CC. Jt Comm J Qual Patient Saf. 2013;39:195-204.

NEWSPAPER/MAGAZINE ARTICLE

Driving out errors, with mom in mind.

Weinstock M. Hosp Health Netw. April 2011.

BOOK/REPORT

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

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

SPECIAL OR THEME ISSUE

Patient Safety and Quality.

Lyndon A, Simpson KR, Bakewell-Sachs S, eds. J Perinat Neonat Nurs. 2010;24:1-89.

STUDY

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

Wetterneck TB, Walker JM, Blosky MA, et al. J Am Med Inform Assoc. 2011;18:774-782.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

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

TOOLKIT

Wristband Standardization Initiative.

Austin, TX: Texas Hospital Association; October 2008.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

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