AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (13)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (125)

•Medical Complications (75)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (19)

•Transfusion Complications (1)

•Psychological and Social Complications (7)

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•Australia and New Zealand (34)

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•Book/Report (10)

•Clinical Guideline (1)

•Journal Article (245)

•Legislation/Regulation (4)

•Newspaper/Magazine Article (32)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

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Error Types

•Epidemiology of Errors and Adverse Events (95)

•Active Errors (37)

•Latent Errors (9)

•Near Miss (2)

Approach to Improving Safety
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Specialization of Care

•Specialized Teams (143)

•Intensivists and Other ICU Strategies (8)

•Hospitalists (16)

•Volume-Based Referral (1)

•Clinical Pharmacist Involvement (93)

Clinical Areas

•Medicine (257)

•Nursing (28)

•Pharmacy (78)

Target Audience

•Health Care Providers (252)

•Health Care Executives and Administrators (258)

•Non-Health Care Professionals (73)

•Patients (14)

Setting of Care

•Hospitals (270)

•Psychiatric Facilities (1)

•Residential Facilities (3)

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•Outpatient Surgery (1)

•Patient Transport (3)

1 - 20 of 301

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REVIEW

"Tech-check-tech": a review of the evidence on its safety and benefits.

Adams AJ, Martin SJ, Stolpe SF. Am J Health Syst Pharm. 2011;68:1824-1833.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

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.

COMMENTARY

Inappropriate Antibiotic Use.

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

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors in the emergency department: need for pharmacy involvement?

PA-PSRS Patient Saf Advis. March 2011;8:1-7.

STUDY

The impact of the medical emergency team on the resuscitation practice of critical care nurses.

Santiano N, Young L, Baramy LS, et al; Clinical Analysis Group. BMJ Qual Saf. 2011;20:115-120.

STUDY

Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital.

Chan EW, Taylor SE, Marriott JL, Barger B. Med J Aust. 2009;191:374-377.

STUDY

Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment.

Markert A, Thierry V, Kleber M, Behrens M, Engelhardt M. Int J Cancer. 2009;124:722-728.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

STUDY

The impact of introducing medical emergency team system on the documentations of vital signs.

Chen J, Hillman K, Bellomo R, Flabouris A, Finfer S, Cretikos M; MERIT Study Investigators for the Simpson Centre and ANZICS Clinical Trials Group. Resuscitation. 2009;80:35-43.

STUDY

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation.

Schneider A, Calzavacca P, Jones D, Bellomo R. Resuscitation. 2011;82:410-414.

REVIEW

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. CMAJ. 2005;173:510-515.

STUDY

What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.

Shearer B, Marshall S, Buist MD, et al. BMJ Qual Saf. 2012;21:569-575.

STUDY

Timing and interventions of emergency teams during the MERIT study.

Flabouris A, Chen J, Hillman K, Bellomo R, Finfer S; The MERIT Study Investigators from the Simpson Centre and the ANZICs Clinical Trials Group. Resuscitation. 2010;81:25-30.

COMMENTARY

Rapid response systems: from implementation to evidence base.

Sarani B, Scott S. Jt Comm J Qual Patient Saf. 2010;36:514-517.

STUDY

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.

Mitchell IA, McKay H, Van Leuvan C, et al. Resuscitation. 2010;81:658-666.

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