AHRQ Patient Safety Network

PATIENT SAFETY PRIMERS
Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (20)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (150)

•Medical Complications (106)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (84)

•Transfusion Complications (3)

•Psychological and Social Complications (40)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (20)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (614)

•Legislation/Regulation (11)

•Meeting/Conference (16)

•Newspaper/Magazine Article (94)

•Press Release/Announcement (4)

•Special or Theme Issue (39)

•Tools/Toolkit (19)

•Web Resource (28)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (91)

•Active Errors (59)

•Latent Errors (66)

•Near Miss (14)

Approach to Improving Safety
< All

Culture of Safety

•Learning Organization (53)

•Red Rules (2)

•Institutional Patient Safety Plan (27)

•Just Culture (25)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (551)

•Health Care Executives and Administrators (845)

•Non-Health Care Professionals (441)

•Patients (59)

Setting of Care

•Hospitals (571)

•Psychiatric Facilities (4)

•Residential Facilities (25)

•Ambulatory Care (62)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 968

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STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

COMMENTARY

Developing a medication patient safety program, part 2: process and implementation.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:249–254.

COMMENTARY

Developing a medication patient safety program — infrastructure and strategy.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

STUDY

Hospital governance and the quality of care.

Jha AK, Epstein AM. Health Aff (Millwood). 2010;29:182-187.

STUDY

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

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

STUDY

Identifying organizational cultures that promote patient safety.

Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311.

NEWSPAPER/MAGAZINE ARTICLE

'Spread' remains challenge in patient safety improvement.

Healthcare Benchmarks Qual Improv. 2011;18:49-52.

STUDY

How event reporting by US hospitals has changed from 2005 to 2009.

Farley DO, Haviland A, Haas A, Pham C, Munier WB, Battles JB. BMJ Qual Saf. 2012;21:70-77.

STUDY

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

MEETING/CONFERENCE PROCEEDINGS

The Role of HR in Quality and Patient Safety.

The American Society for Healthcare Human Resources Administration. San Diego, CA: July 24, 2008.

STUDY

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.

Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

NEWSPAPER/MAGAZINE ARTICLE

Leading a culture of safety.

Sandrick K. Trustee. July/August 2009;62:6-10.

STUDY

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.

Fareed N, Mick SS. Health Care Manage Rev. 2011;36:288-298.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

REVIEW

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

Goeschel CA, Wachter RM, Pronovost PJ. Chest. 2010;138:171-178.

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