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 (28)

•Diagnostic Errors (11)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (37)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (124)

•Medical Complications (91)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (81)

•Transfusion Complications (2)

•Psychological and Social Complications (40)

Origin/Sponsor

•Africa (1)

•Asia (6)

•Australia and New Zealand (20)

Resource Types

•Clinical Guideline (1)

•Journal Article (594)

•Legislation/Regulation (9)

•Meeting/Conference (15)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (4)

•Special or Theme Issue (35)

•Tools/Toolkit (13)

•Web Resource (26)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (80)

•Active Errors (50)

•Latent Errors (55)

•Near Miss (11)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (55)

•Red Rules (2)

•Institutional Patient Safety Plan (17)

•Just Culture (19)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (519)

•Health Care Executives and Administrators (810)

•Non-Health Care Professionals (466)

•Patients (60)

Setting of Care

•Hospitals (514)

•Psychiatric Facilities (3)

•Residential Facilities (24)

•Ambulatory Care (48)

•Outpatient Surgery (5)

•Patient Transport (7)

1 - 20 of 924

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COMMENTARY

A leadership initiative to improve communication and enhance safety.

Donahue M, Miller M, Smith L, Dykes P, Fitzpatrick JJ. Am J Med Qual. 2011;26:206-211.

COMMENTARY

Disruptive clinician behavior: a persistent threat to patient safety.

Porto G, Lauve R. Patient Safety Qual Healthc. July/August 2006;3:16-24.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

Stories from the sharp end: case studies in safety improvement.

McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

STUDY

Improving patient safety: effects of a safety program on performance and culture in a department of radiology.

Donnelly LF, Dickerson JM, Goodfriend MA, Muething SE. AJR Am J Roentgenol. 2009;193:165-171.

STUDY

Factors associated with disclosure of medical errors by housestaff.

Kronman AC, Paasche-Orlow M, Orlander JD. BMJ Qual Saf. 2012;21:271-278.

PRESS RELEASE/ANNOUNCEMENT

AHA-NPSF Comprehensive Patient Safety Leadership Fellowship.

American Hospital Association, National Patient Safety Foundation.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

COMMENTARY

Patient safety: mindful, meaningful, and fulfilling.

Winokur SC, Beauregard KJ. Frontiers Health Serv Manag. 2005;22:17-32.

STUDY

Organizational culture, critical success factors, and the reduction of hospital errors.

Stock GN, McFadden KL, Gowen III, CR. Int J Prod Econ. 2007;106:368–392.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing violence in the health care setting.

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

COMMENTARY

Improving hospital performance: culture change is not the answer.

Leggat SG, Dwyer J. Healthc Q. 2005;8:60-68.

MEETING/CONFERENCE PROCEEDINGS

2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.

Agency for Healthcare Research and Quality. June 6-10, 2005.

STUDY

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

MULTI-USE WEBSITE

Centre for Patient Safety and Service Quality.

Department of Bio-Surgery & Surgical Technology, Imperial College of Science & Technology. 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London W2 1NY, United Kingdom.

REVIEW

Intimidation: a concept analysis.

Lamontagne C. Nurs Forum. 2010;45:54-65.

COMMENTARY

Developing a national patient safety education framework for Australia.

Walton MM, Shaw T, Barnet S, Ross J. Qual Saf Health Care. 2006;15:437-442.

SPECIAL OR THEME ISSUE

Improving the Health Care Work Environment.

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

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