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 (18)

•Identification Errors (13)

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

•Fatigue and Sleep Deprivation (6)

•Medication Safety (121)

•Medical Complications (90)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (71)

•Transfusion Complications (2)

•Psychological and Social Complications (29)

Origin/Sponsor

•Africa (1)

•Asia (5)

•Australia and New Zealand (23)

•Central and South America (3)

Resource Types

•Journal Article (488)

•Legislation/Regulation (11)

•Meeting/Conference (15)

•Newspaper/Magazine Article (74)

•Press Release/Announcement (4)

•Special or Theme Issue (27)

•Tools/Toolkit (18)

•Web Resource (23)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (74)

•Active Errors (72)

•Latent Errors (81)

•Near Miss (15)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (27)

•Red Rules (2)

•Institutional Patient Safety Plan (8)

•Just Culture (14)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (512)

•Health Care Executives and Administrators (694)

•Non-Health Care Professionals (383)

•Patients (50)

Setting of Care

•Hospitals (460)

•Psychiatric Facilities (4)

•Residential Facilities (20)

•Ambulatory Care (55)

•Outpatient Surgery (3)

•Patient Transport (8)

1 - 20 of 781

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BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

COMMENTARY

Moving Pains

Schell H, Wachter RM. AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

REVIEW

The high-reliability pediatric intensive care unit.

Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

STUDY

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

STUDY

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. Qual Saf Health Care. 2008;17:25-30.

AWARD RECIPIENT

A comprehensive grassroots model for statewide safety improvement.

Joshi M, Kazandjian V, Martin P, et al. Jt Comm J Qual Patient Saf. 2005;31:671-677.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Changing the work environment in ICUs to achieve patient-focused care: the time has come.

McCauley K, Irwin RS. Chest. 2006;130:1571-1578.

SPECIAL OR THEME ISSUE

Safety.

Simmons D, ed. Crit Care Nurs Clin North Am. 2010;22:161-290.

PRESS RELEASE/ANNOUNCEMENT classic

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

GRANT RECIPIENT

Improving Patient Safety Through Simulation Research.

Rockville, MD: Agency for Healthcare Research and Quality; June 2008.

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