AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (20)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (116)

•Fatigue and Sleep Deprivation (100)

•Medication Safety (111)

•Medical Complications (45)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (41)

•Transfusion Complications (4)

•Psychological and Social Complications (12)

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•Australia and New Zealand (7)

•North America (388)

Resource Types

•Audiovisual (2)

•Book/Report (17)

•Journal Article (333)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (61)

•Special or Theme Issue (6)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (82)

•Active Errors (50)

•Latent Errors (49)

•Near Miss (7)

Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (56)

•Nurse Staffing Ratios (38)

•Scheduling Changes (26)

•Duty Hour Limitation (119)

Clinical Areas

•Medicine (273)

•Nursing (74)

•Pharmacy (43)

Target Audience

•Health Care Providers (313)

•Health Care Executives and Administrators (334)

•Non-Health Care Professionals (184)

•Patients (32)

Setting of Care

•Hospitals (335)

•Psychiatric Facilities (1)

•Residential Facilities (7)

•Ambulatory Care (37)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 434

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AWARD RECIPIENT

Building and sustaining a systemwide culture of safety.

Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke G, Merti GE. Jt Comm J Qual Patient Saf. 2005;31:684-689.

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

Maternity ward at Highland under fire from patients.

Vesely R. Inside Bay Area. December 28, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.

Russell S. San Francisco Chronicle. June 24, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals move to cut dangerous lab errors.

Landro L. Wall Street Journal (Eastern edition). June 14, 2006:D1. [Reprinted on Post-gazette.com].

COMMENTARY

No excuses: the reality that demands action.

Denham C, Bagian J, Daley J, et al. J Patient Safety. 2005;1:154-169.

NEWSPAPER/MAGAZINE ARTICLE

Technology has transformed the VA.

Stires D. Fortune Magazine. May 15, 2006:130-132, 134, 136.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Managing health care worker fatigue: maximizing alertness to keep patients safe.

Joint Commission: The Source. February 2012;10:1-5.

STUDY

Mortality rate after nonelective hospital admission.

Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Arch Surg. 2011;146:545-551.

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

Association between Leapfrog safe practices score and hospital mortality in major surgery.

Qian F, Lustik SJ, Diachun CA, Wissler RN, Zollo RA, Glance LG. Med Care. 2011;49:1082-1088.

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.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

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

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.

COMMENTARY

Sleep deprivation, physician performance, and patient safety.

Olson EJ, Drage LA, Auger RR. Chest. 2009;136:1389-1396.

SPECIAL OR THEME ISSUE

Patient Safety Papers 4.

Baker GR, ed. Healthc Q. 2009;12:1-198.

STUDY

ACGME duty-hour recommendations—a national survey of residency program directors.

Antiel RM, Thompson SM, Reed DA, et al. N Engl J Med. 2010;363:e12.

COMMENTARY

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

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

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