AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (12)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (34)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (63)

•Medical Complications (45)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (21)

•Transfusion Complications (1)

•Psychological and Social Complications (5)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (15)

Resource Types

•Clinical Guideline (1)

•Journal Article (140)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (18)

•Special or Theme Issue (2)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (43)

•Active Errors (34)

•Latent Errors (11)

•Near Miss (1)

Approach to Improving Safety
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Specialization of Care

•Specialized Teams (72)

•Intensivists and Other ICU Strategies (4)

•Hospitalists (11)

•Volume-Based Referral (3)

•Clinical Pharmacist Involvement (43)

Clinical Areas

•Medicine (153)

•Nursing (16)

•Pharmacy (37)

Target Audience

•Health Care Providers (162)

•Health Care Executives and Administrators (146)

•Non-Health Care Professionals (53)

•Patients (10)

Setting of Care

•Hospitals (144)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (11)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 171

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COMMENTARY

Dangerous Dapsone.

Bookwalter T. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

When “Psychiatric” Symptoms are Not.

Goldberg RJ. AHRQ WebM&M [serial online]. February 2003.

MULTI-USE WEBSITE

Standardization Projects.

Washington State Hospital Association.

COMMENTARY

Vial Mistakes Involving Heparin.

Vanderveen T. AHRQ WebM&M [serial online]. May 2009.

COMMENTARY

Language barriers to health care in the United States.

Flores G. N Engl J Med. 2006;355:229-231.

STUDY

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.

Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.

STUDY

Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls.

Stauffer BD, Fullerton C, Fleming N, et al. Arch Intern Med. 2011;171:1238-1243.

COMMENTARY

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

Clancy CM. Am J Med Qual. 2009;24:344-346.

MULTI-USE WEBSITE

Project Red (Re-Engineered Discharge).

Boston, MA: Boston University Medical Center.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

STUDY

Impact of a comprehensive patient safety strategy on obstetric adverse events.

Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009 May;200:492.e1-8.

COMMENTARY

Failure to Latch

Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.

STUDY

Relationship between patient safety and hospital surgical volume.

Hernandez-Boussard T, Downey JR, McDonald K, Morton JM. Health Serv Res. 2012;47:756-769.

COMMENTARY

Inappropriate Antibiotic Use.

Babcock HM, Fraser VJ. AHRQ WebM&M [serial online]. June 2003.

STUDY

The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Weller JM, Merry AF, Robinson BJ, Warman GR, Janssen A. Anaesthesia. 2009;64:126-130.

STUDY

A comprehensive obstetrics patient safety program improves safety climate and culture.

Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-e6.

STUDY

No harm found when nurse anesthetists work without supervision by physicians.

Dulisse B, Cromwell J. Health Aff (Millwood). 2010;29:1469-1475.

NEWSPAPER/MAGAZINE ARTICLE

Personal best.

Gawande A. New Yorker. October 3, 2011.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

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