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 (30)

•Diagnostic Errors (19)

•Identification Errors (13)

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

•Fatigue and Sleep Deprivation (6)

•Medication Safety (135)

•Medical Complications (104)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (80)

•Transfusion Complications (2)

•Psychological and Social Complications (42)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (608)

•Legislation/Regulation (10)

•Meeting/Conference (16)

•Newspaper/Magazine Article (93)

•Press Release/Announcement (4)

•Special or Theme Issue (33)

•Tools/Toolkit (19)

•Web Resource (26)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (89)

•Active Errors (61)

•Latent Errors (67)

•Near Miss (14)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (51)

•Red Rules (2)

•Institutional Patient Safety Plan (26)

•Just Culture (22)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (545)

•Health Care Executives and Administrators (827)

•Non-Health Care Professionals (440)

•Patients (58)

Setting of Care

•Hospitals (569)

•Psychiatric Facilities (4)

•Residential Facilities (25)

•Ambulatory Care (60)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 949

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NEWSPAPER/MAGAZINE ARTICLE

That’s the way we do things around here!

ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.

COMMENTARY

Do Not Disturb!

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

STUDY

An organizational assessment of disruptive clinician behavior: findings and implications.

Walrath JM, Dang D, Nyberg D. J Nurs Care Qual. 2013;28:110-121.

COMMENTARY

Perspective: a culture of respect—part 1 and part 2.

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012;87:845-858.

NEWSPAPER/MAGAZINE ARTICLE

Team-based care.

Weinstock M. Hosp Health Netw. March 2010;84:6p following 28,2.

STUDY

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts.

Fried JM, Vermillion M, Parker NH, Uijtdehaage S. Acad Med. 2012;87:1191-1198.

COMMENTARY

How to develop a second victim support program: a toolkit for health care organizations.

Pratt S, Kenney L, Scott SD, Wu AW. Jt Comm J Qual Patient Saf. 2012;38:235-240.

REVIEW

Reducing hospital errors: interventions that build safety culture.

Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.

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

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.

COMMENTARY

A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.

Scott C, Gerardi D. Jt Comm J Qual Patient Saf. 2011;37:59-69, 70-80.

STUDY

Active learning: when is more better? The case of resident physicians' medical errors.

Katz-Navon T, Naveh E, Stern Z. J Appl Psychol. 2009;94:1200-1209.

COMMENTARY

The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.

Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2010;15:1-4.

BOOK/REPORT

Charting the Course: Launching Patient-Centric Healthcare.

Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.

STUDY

Workplace engagement and workers' compensation claims as predictors for patient safety culture.

Thorp J, Baqai W, Witters D, et al. J Patient Saf. 2012;8:194-201.

COMMENTARY

Physicians with multiple patient complaints: ending our silence.

Gallagher TH, Levinson W. BMJ Qual Saf. 2013 Apr 18; [Epub ahead of print].

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.

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