AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (21)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (125)

•Fatigue and Sleep Deprivation (110)

•Medication Safety (124)

•Medical Complications (50)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (41)

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•Special or Theme Issue (7)

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Error Types

•Epidemiology of Errors and Adverse Events (109)

•Active Errors (58)

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Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (65)

•Nurse Staffing Ratios (48)

•Scheduling Changes (29)

•Duty Hour Limitation (131)

Clinical Areas

•Medicine (301)

•Nursing (90)

•Pharmacy (44)

Target Audience

•Health Care Providers (343)

•Health Care Executives and Administrators (365)

•Non-Health Care Professionals (191)

•Patients (28)

Setting of Care

•Hospitals (360)

•Psychiatric Facilities (1)

•Residential Facilities (6)

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•Patient Transport (4)

1 - 20 of 471

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STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

STUDY

The association between night or weekend admission and hospitalization-relevant patient outcomes.

Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. J Hosp Med. 2011;6:10-14.

STUDY

Effect of hospital follow-up appointment on clinical event outcomes and mortality.

Grafft CA, McDonald FS, Ruud KL, Liesinger JT, Johnson MG, Naessens JM. Arch Intern Med. 2010;170:955-960.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

REVIEW

classic

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.

STUDY

Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.

Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. J Acad Nutr Diet. 2012;112:1656-1661.

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

STUDY

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

Taylor JA, Dominici F, Agnew J, Gerwin D, Morlock L, Miller MR. BMJ Qual Saf. 2012;21:101-111.

NEWSPAPER/MAGAZINE ARTICLE

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

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

NEWSPAPER/MAGAZINE ARTICLE

Shifting the risks at night.

Boodman SG. Washington Post. June 7, 2011:E7.

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].

STUDY

The effects of a mid-day nap on the neurocognitive performance of first-year medical residents: a controlled interventional pilot study.

Amin MM, Graber M, Ahmad K, et al. Acad Med. 2012;87:1428-1433.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

COMMENTARY

Residents' duty hours—toward an empirical narrative.

Rosenbaum L, Lamas D. N Engl J Med. 2012;367:2044-2049.

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