AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (4)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (43)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (94)

•Medical Complications (39)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (14)

•Transfusion Complications (3)

•Psychological and Social Complications (11)

Origin/Sponsor

•Australia and New Zealand (13)

•North America (186)

Resource Types

•Audiovisual (1)

•Book/Report (10)

•Journal Article (177)

•Legislation/Regulation (5)

•Newspaper/Magazine Article (28)

•Press Release/Announcement (1)

•Special or Theme Issue (8)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (53)

•Active Errors (30)

•Latent Errors (31)

•Near Miss (9)

Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (14)

•Nurse Staffing Ratios (60)

•Scheduling Changes (13)

•Duty Hour Limitation (24)

Clinical Areas

•Allied Health Services (1)

•Medicine (105)

•Nursing (116)

•Pharmacy (26)

Target Audience

•Health Care Providers (177)

•Health Care Executives and Administrators (198)

•Non-Health Care Professionals (55)

•Patients (12)

Setting of Care

•Hospitals (185)

•Psychiatric Facilities (2)

•Residential Facilities (9)

•Ambulatory Care (20)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 232

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STUDY

Nurses relate the contributing factors involved in medication errors.

Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. J Clin Nurs. 2007;16:447-457.

STUDY

Effects of nursing rounds on patients' call light use, satisfaction, and safety.

Meade CM, Bursell AL, Ketelsen L. Am J Nurs. 2006;106:58-70.

STUDY

classic

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

STUDY

Daytime sleepiness, sleep habits and occupational accidents among hospital nurses.

Suzuki K, Ohida T, Kaneita Y, Yokoyama E, Uchiyama M. J Adv Nurs. 2005;52:445-453.

PENNSYLVANIA LEGISLATION

Prohibition of Excessive Overtime for Nurses Act.

The General Assembly of Pennsylvania. HB957 (2005).

STUDY

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.

Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. Crit Care Nurse. 2010;30:21-29.

STUDY

Quantifying nursing workflow in medication administration.

Keohane CA, Bane AD, Featherstone E, et al. J Nurs Admin. 2008;38:19-26.

COMMENTARY

Medication room madness: calming the chaos.

Conrad C, Fields W, McNamara T, Cone M. J Nurs Care Qual. 2009;25:137-144.

COMMENTARY

Interruptions and medication errors: part I.

Flanders S, Clark AP. Clin Nurse Spec. 2010;24:281-285.

STUDY

Nurses' practice environments, error interception practices, and inpatient medication errors.

Flynn L, Liang Y, Dickson GL, Xie M, Suh DC. J Nurs Scholarsh. 2012;44:180-186.

STUDY

Implementing a fatigue countermeasures program for nurses: a focus group analysis.

Scott LD, Hofmeister N, Rogness N, Rogers AE. J Nurs Adm. 2010;40:233-240.

STUDY

Expanding what we know about off-peak mortality in hospitals.

Hamilton P, Mathur S, Gemeinhardt G, Eschiti V, Campbell M. J Nurs Admin. 2010;40:124-128.

STUDY

Antecedents of severe and nonsevere medication errors.

Chang YK, Mark BA. J Nurs Scholarsh. 2009;41:70-78.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

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.

STUDY

Influence of unit-level staffing on medication errors and falls in military hospitals.

Breckenridge-Sproat S, Johantgen M, Patrician P. West J Nurs Res. 2012;34:455-474.

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.

STUDY

Nursing care quality and adverse events in US hospitals.

Lucero RJ, Lake ET, Aiken LH. J Clin Nurs. 2010;19:2185-2195.

NEWSPAPER/MAGAZINE ARTICLE

Guidelines for timely medication administration: response to the CMS "30-minute rule."

ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.

STUDY

Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units.

Bae SH, Mark B, Fried B. Health Care Manage Rev. 2010;35:333-344.

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