AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (7)

•Diagnostic Errors (22)

•Identification Errors (19)

•Discontinuities, Gaps, and Hand-Off Problems (129)

•Fatigue and Sleep Deprivation (87)

•Medication Safety (102)

•Medical Complications (40)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (45)

•Transfusion Complications (4)

•Psychological and Social Complications (10)

Origin/Sponsor

•Australia and New Zealand (8)

•North America (358)

Resource Types

•Audiovisual (2)

•Book/Report (17)

•Journal Article (302)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (59)

•Special or Theme Issue (8)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (74)

•Active Errors (53)

•Latent Errors (47)

•Near Miss (6)

Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (57)

•Nurse Staffing Ratios (28)

•Scheduling Changes (26)

•Duty Hour Limitation (100)

Clinical Areas

•Allied Health Services (1)

•Medicine (260)

•Nursing (59)

•Pharmacy (40)

Target Audience

•Health Care Providers (287)

•Health Care Executives and Administrators (310)

•Non-Health Care Professionals (170)

•Patients (32)

Setting of Care

•Hospitals (285)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (36)

•Outpatient Surgery (3)

•Patient Transport (4)

1 - 20 of 403

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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

Technology has transformed the VA.

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

COMMENTARY

Safe use of cellular telephones in hospitals: fundamental principles and case studies.

Cohen T, Ellis WS, Morrissey JJ, Bakuzonis C, David Y, Paperman WD. J Healthc Inf Manag. Fall 2005;19:38-48.

COMMENTARY

Waiting Too Long.

Rosen MA. AHRQ WebM&M [serial online]. November 2003.

GRANT ANNOUNCEMENT

AHRQ Health Services Research Projects (R01).

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

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].

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

No hidden patient: a safety design model.

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

COMMENTARY

No excuses: the reality that demands action.

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

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

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

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.

SPECIAL OR THEME ISSUE

Safety in EMS.

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

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.

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.

SPECIAL OR THEME ISSUE

Improving the Health Care Work Environment.

Jt Comm J Qual Patient Saf. November 2007;33(suppl 1):3-84.

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

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.

STUDY

Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer.

Young JQ, Niehaus B, Lieu SC, O'Sullivan PS. Acad Med. 2010;85:1418-1424.

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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