AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (12)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (96)

•Fatigue and Sleep Deprivation (59)

•Medication Safety (82)

•Medical Complications (38)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (26)

•Transfusion Complications (5)

•Psychological and Social Complications (12)

Origin/Sponsor

•Australia and New Zealand (8)

•Central and South America (1)

•North America (253)

Resource Types

•Audiovisual (1)

•Book/Report (16)

•Journal Article (218)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newspaper/Magazine Article (40)

•Special or Theme Issue (6)

•Tools/Toolkit (2)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (53)

•Active Errors (31)

•Latent Errors (39)

•Near Miss (7)

Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (25)

•Nurse Staffing Ratios (18)

•Scheduling Changes (19)

•Duty Hour Limitation (66)

Clinical Areas

•Medicine (184)

•Nursing (53)

•Pharmacy (32)

Target Audience

•Health Care Providers (197)

•Health Care Executives and Administrators (246)

•Non-Health Care Professionals (128)

•Patients (19)

Setting of Care

•Hospitals (237)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (19)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 297

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NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

GRANT ANNOUNCEMENT

AHRQ Health Services Research Projects (R01).

US Department of Health and Human Services. Program Announcement No. PA-09-070.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

NEWSPAPER/MAGAZINE ARTICLE

No hidden patient: a safety design model.

Hardy J. Trustee. February 2007;60:32-33.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

STUDY

'August is always a nightmare': results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey.

Vaughan L, McAlister G, Bell D. Clin Med. 2011;11:322-326.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

STUDY

Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.

van Walraven C, Jennings A, Wong J, Forster AJ. J Hosp Med. 2011;6:389-394.

COMMENTARY

Workarounds and Resiliency on the Front Lines of Health Care

Tucker AL. AHRQ WebM&M [serial online]. August 2009.

REVIEW

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

O'Leary KJ, Sehgal NL, Terrell G, Williams MV; High Performance Teams and the Hospital of the Future Project Team. J Hosp Med. 2011 Oct 31; [Epub ahead of print].

SPECIAL OR THEME ISSUE

Adverse events: expecting too much of nurses and too little of nursing research.

Jordan S, ed. J Nurs Manag. 2011;19:287-417.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2010;15:1-4.

STUDY

Weekend versus weekday admission and mortality from myocardial infarction.

Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE, for the Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group. N Engl J Med. 2007;356:1099-1109.

SPECIAL OR THEME ISSUE

Safety in EMS.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

BOOK/REPORT

Characteristics of Weekday and Weekend Hospital Admissions, 2007.

Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.

REVIEW

classic

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.

STUDY

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

Hall LM, Ferguson-Paré M, Peter E, et al. J Nurs Manag. 2010;18:1040-1047.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

Sentinel Event Alert. June 3, 2010;(45):1-3.

BOOK/REPORT

Addressing the quality and safety gap—parts I-II.

Princeton, NJ: Robert Wood Johnson Foundation; July 2009.

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