AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Discontinuities, Gaps, and Hand-Off Problems (14)

•Medication Safety (28)

•Medical Complications (49)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (11)

•Psychological and Social Complications (1)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (6)

•Europe (6)

•North America (142)

Resource Types

•Book/Report (5)

•Journal Article (125)

•Newspaper/Magazine Article (21)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

Error Types

•Epidemiology of Errors and Adverse Events (23)

•Active Errors (8)

•Latent Errors (3)

Approach to Improving Safety
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Specialized Teams

•Unit Based Safety Teams (16)

•Rapid Response Team (99)

Clinical Areas

•Medicine (137)

•Nursing (23)

•Pharmacy (6)

Target Audience

•Health Care Providers (104)

•Health Care Executives and Administrators (141)

•Non-Health Care Professionals (35)

•Patients (12)

Setting of Care

•Hospitals (138)

•Ambulatory Care (4)

•Patient Transport (1)

1 - 20 of 155

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NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

STUDY

Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial.

McGregor JC, Weekes E, Forrest GN, et al. J Am Med Inform Assoc. 2006;13:378-384.

COMMENTARY

Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.

Franco AC, Maxwell P, Green K, Barthol C. Hosp Pharm. 2009;44:776-780, 784.

COMMENTARY

A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.

Weinstein L. Am J Obstet Gynecol. 2006;194:1160-1165; discussion 1165-1167.

STUDY

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Abstoss KM, Shaw BE, Owens TA, Juno JL, Commiskey EL, Niedner MF. BMJ Qual Saf. 2011;914-922.

STUDY

Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

Morris DS, Schweickert W, Holena D, et al. Resuscitation. 2012;83:1434-1437.

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

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

BOOK/REPORT

Committed to Safety: Ten Case Studies on Reducing Harm to Patients.

McCarthy D, Blumenthal D. New York, NY: The Commonwealth Fund; April 2006.

BOOK/REPORT

How-to Guide: Multidisciplinary Rounds.

Cambridge, MA: Institute for Healthcare Improvement; February 2010.

NEWSPAPER/MAGAZINE ARTICLE

Preventing medication errors during codes.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2011;16:1-3.

STUDY

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

REVIEW

Rapid response teams: a systematic review and meta-analysis.

Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Arch Intern Med. 2010;170:18-26.

STUDY

Rapid response teams and continuous quality improvement.

Dailey MS, Durkin S, Gulczynski B, Kearney M, Loeb B, Pouliot J. Patient Saf Qual Healthc. Nov/Dec 2009;6:28-31.

COMMENTARY

The creation and impact of a dedicated section on quality and patient safety in a clinical academic department.

Boudreaux AM, Vetter TR. Acad Med. 2013;88:173-178.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

COMMENTARY

The growth of rapid response systems.

Steel AC, Reynolds SF. Jt Comm J Qual Patient Saf. 2008;34:489-495.

STUDY

Rapid response teams seen through the eyes of the nurse.

Shapiro SE, Donaldson NE, Scott MB. Am J Nurs. 2010;110:28-34.

STUDY

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests.

DeVita MA, Braithwaite RS, Mahidhara R, et al. Qual Saf Health Care. 2004;13:251-254.

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