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 (25)

•Diagnostic Errors (18)

•Identification Errors (17)

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

•Fatigue and Sleep Deprivation (7)

•Medication Safety (121)

•Medical Complications (97)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (105)

•Transfusion Complications (2)

•Psychological and Social Complications (38)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (25)

•Central and South America (2)

Resource Types

•Journal Article (554)

•Legislation/Regulation (10)

•Meeting/Conference (16)

•Newspaper/Magazine Article (82)

•Press Release/Announcement (3)

•Special or Theme Issue (33)

•Tools/Toolkit (17)

•Web Resource (23)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (76)

•Active Errors (61)

•Latent Errors (78)

•Near Miss (16)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (41)

•Red Rules (2)

•Institutional Patient Safety Plan (16)

•Just Culture (15)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (531)

•Health Care Executives and Administrators (763)

•Non-Health Care Professionals (450)

•Patients (54)

Setting of Care

•Hospitals (500)

•Psychiatric Facilities (4)

•Residential Facilities (21)

•Ambulatory Care (54)

•Outpatient Surgery (6)

•Patient Transport (7)

1 - 20 of 862

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STUDY

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

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

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

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.

STUDY

Organisational culture: variation across hospitals and connection to patient safety climate.

Speroff T, Nwosu S, Greevy R, et al. Qual Saf Health Care. 2010;19:592-596.

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.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

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].

STUDY

The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.

Parand A, Burnett S, Benn J, Pinto A, Iskander S, Vincent C. J Eval Clin Pract. 2010;17:1184-1190.

MULTI-USE WEBSITE

Safer Healthcare Now!

Canadian Patient Safety Institute.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.

NEWSPAPER/MAGAZINE ARTICLE

Leadership practices to advance patient safety.

Crowley JD, Deen JB. Patient Saf Qual Healthc. May/June 2009;6:18-22.

MULTI-USE WEBSITE

The Patient Safety Group.

Boston, MA.

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

BOOK/REPORT classic

Advances in Patient Safety: New Directions and Alternative Approaches.

Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).

SPECIAL OR THEME ISSUE

The English Patient Safety Programme.

J Health Serv Research Pol. 2010;15(suppl 1):S1-S91.

COMMENTARY

Do Not Disturb!

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

COMMENTARY

The Preventable Harm Index: an effective motivator to facilitate the drive to zero.

Brilli RJ, McClead RE Jr, Davis T, Stoverock L, Rayburn A, Berry JC. J Pediatr. 2010;157:681-683.

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