AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (9)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (61)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (33)

•Medical Complications (29)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (64)

•Transfusion Complications (1)

•Psychological and Social Complications (30)

Origin/Sponsor

•Australia and New Zealand (10)

•North America (193)

Resource Types

•Audiovisual (2)

•Book/Report (13)

•Journal Article (209)

•Legislation/Regulation (2)

•Meeting/Conference (2)

•Newspaper/Magazine Article (19)

•Special or Theme Issue (14)

•Tools/Toolkit (5)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (19)

•Active Errors (26)

•Latent Errors (16)

•Near Miss (2)

Approach to Improving Safety
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Teamwork

•Teamwork Training (38)

Clinical Areas

•Medicine (184)

•Nursing (75)

•Pharmacy (3)

Target Audience

•Health Care Providers (211)

•Health Care Executives and Administrators (232)

•Non-Health Care Professionals (134)

•Patients (12)

Setting of Care

•Hospitals (199)

•Residential Facilities (5)

•Ambulatory Care (12)

•Outpatient Surgery (4)

•Patient Transport (5)

1 - 20 of 278

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STUDY

Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events.

Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. J Nurs Care Qual. 2012;27:43-50.

STUDY

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

Haan JM, Dutton RP, Willis M, Leone S, Kramer ME, Scalea TM. J Trauma. 2007;63:339-343.

MULTI-USE WEBSITE

Simulation Training for Rapid Assessment & Improved Teamwork (STRAIT) Project.

Center for Perioperative Research in Quality, Vanderbilt University.

STUDY

Why nurses make medication errors: a simulation study.

Kazaoka T, Ohtsuka K, Ueno K, Mori M. Nurse Educ Today. 2007;27:312-17.

STUDY

Nurse and nurse assistant perceptions of missed nursing care: what does it tell us about teamwork?

Kalisch BJ. J Nurs Adm. 2009;39:485-493.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

STUDY

Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes.

Hughes CM, Lapane KL. Int J Qual Health Care. 2006;18:281-286.

STUDY

Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.

Nestel D, Kidd JM. BMC Nurs. 2006 Feb 8;5:1.

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

REVIEW

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

COMMENTARY

Safety huddles in the PACU: when a patient self-medicates.

Setaro J, Connolly M. J Perianesth Nurs. 2011;26:96-102.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic.

Blough CA, Walrath JM. J Nurs Care Qual. 2007;22:159-163.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

ORGANIZATIONAL POLICY/GUIDELINES

AORN guidance statement: creating a patient safety culture.

AORN J. 2006;83:936-942.

STUDY

Worries and concerns experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident study.

Gustafsson M, Wennerholm S, Fridlund B. Intensive Crit Care Nurs. 2010;26:138-145.

STUDY

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.

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