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 (15)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (40)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (133)

•Medical Complications (102)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (80)

•Transfusion Complications (2)

•Psychological and Social Complications (40)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (16)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (588)

•Legislation/Regulation (12)

•Meeting/Conference (17)

•Newspaper/Magazine Article (95)

•Press Release/Announcement (4)

•Special or Theme Issue (32)

•Tools/Toolkit (16)

•Web Resource (25)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (88)

•Active Errors (52)

•Latent Errors (60)

•Near Miss (13)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (50)

•Red Rules (2)

•Institutional Patient Safety Plan (24)

•Just Culture (23)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (527)

•Health Care Executives and Administrators (811)

•Non-Health Care Professionals (432)

•Patients (63)

Setting of Care

•Hospitals (549)

•Psychiatric Facilities (5)

•Residential Facilities (25)

•Ambulatory Care (50)

•Outpatient Surgery (5)

•Patient Transport (6)

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NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

BOOK/REPORT classic

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.

London, England: The Stationery Office; July 2001.

STUDY

Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation.

Frankel A, Grillo SP, Baker EG, et al. Jt Comm J Qual Patient Saf. 2005;31:423-437.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

AUDIOVISUAL

Eye to eye: Donald Berwick.

"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.

NEWSPAPER/MAGAZINE ARTICLE

How safe do patients feel?

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

BOOK/REPORT

How Safe Is Your Hospital?

Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.

MULTI-USE WEBSITE

MHA Keystone Center for Patient Safety and Quality.

Michigan Health and Hospital Association.

STUDY

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.

Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.

COMMENTARY classic

Risk mitigation in large scale systems: lessons from high reliability organizations.

Grabowski M, Roberts KH. Calif Manage Rev. 1997;39:152-162.

BOOK/REPORT classic

Josie's Story.

King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.

AUDIOVISUAL

Good News: How Hospitals Heal Themselves [documentary].

Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.

STUDY

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

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

NEWSPAPER/MAGAZINE ARTICLE

The health factory.

Spear SJ. New York Times. August 29, 2005;Editorials/Op-Ed section:15.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

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

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

BOOK/REPORT

Charting the Course: Launching Patient-Centric Healthcare.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

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

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