AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (10)

•Diagnostic Errors (11)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (58)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (65)

•Medical Complications (57)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (95)

•Psychological and Social Complications (39)

Origin/Sponsor

•Australia and New Zealand (15)

•North America (396)

Resource Types

•Audiovisual (3)

•Book/Report (34)

•Journal Article (363)

•Legislation/Regulation (3)

•Meeting/Conference (3)

•Newspaper/Magazine Article (44)

•Press Release/Announcement (1)

•Special or Theme Issue (29)

•Tools/Toolkit (8)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (42)

•Active Errors (41)

•Latent Errors (22)

•Near Miss (4)

Approach to Improving Safety
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Teamwork

•Teamwork Training (105)

Clinical Areas

•Allied Health Services (2)

•Medicine (342)

•Nursing (66)

•Pharmacy (14)

Target Audience

•Health Care Providers (364)

•Health Care Executives and Administrators (417)

•Non-Health Care Professionals (263)

•Patients (20)

Setting of Care

•Hospitals (338)

•Psychiatric Facilities (2)

•Residential Facilities (5)

•Ambulatory Care (28)

•Outpatient Surgery (4)

•Patient Transport (6)

1 - 20 of 505

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TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

Reconciling medications at admission: safe practice recommendations and implementation strategies.

Rogers G, Alper E, Brunelle D, et al. Jt Comm J Qual Patient Saf. 2006;32:37-50.

STUDY

Family-centered multidisciplinary rounds enhance the team approach in pediatrics.

Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kwoh CK. Pediatrics. 2009;123:e603-e608.

COMMENTARY

Using the Communication and Teamwork Skills (CATS) assessment to measure health care team performance.

Frankel A, Gardner R, Maynard L, Kelly A. Jt Comm J Qual Patient Saf. 2007;33:549-558.

COMMENTARY

Patient safety beyond the hospital.

Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.

COMMENTARY

Integrating CUSP and TRIP to improve patient safety.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

STUDY

Adoption of patient-centered care practices by physicians: results from a national survey.

Audet AM, Davis K, Schoenbaum SC. Arch Intern Med. 2006;166:754-759.

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.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

classic

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

TOOLKIT

Developing a Community-Based Patient Safety Advisory Council.

Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.

BOOK/REPORT classic

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.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

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

NEWSPAPER/MAGAZINE ARTICLE

Simple mistakes, serious consequences: positive ID is no laughing matter.

Edozien L. Saferhealthcare. June 2, 2006.

COMMENTARY

Patient safety in women's health care: a framework for progress.

Gluck PA. Best Pract Res Clin Obstet Gynaecol. 2007;21:525-36.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

COMMENTARY

Learning accountability for patient outcomes.

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

COMMENTARY

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

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