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 (17)

•Diagnostic Errors (14)

•Identification Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (24)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (91)

•Medical Complications (56)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (69)

•Psychological and Social Complications (22)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (8)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (397)

•Legislation/Regulation (4)

•Meeting/Conference (5)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (40)

•Special or Theme Issue (16)

•Tools/Toolkit (10)

•Web Resource (12)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (66)

•Active Errors (68)

•Latent Errors (75)

•Near Miss (14)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (17)

•Red Rules (1)

•Institutional Patient Safety Plan (3)

•Just Culture (12)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (326)

•Health Care Executives and Administrators (472)

•Non-Health Care Professionals (238)

•Patients (21)

Setting of Care

•Hospitals (299)

•Psychiatric Facilities (3)

•Residential Facilities (15)

•Ambulatory Care (36)

•Outpatient Surgery (4)

•Patient Transport (6)

1 - 20 of 532

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COMMENTARY classic

Human error: models and management.

Reason J. BMJ. 2000;320:768-770.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

BOOK/REPORT

Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.

Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.

COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

STUDY

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

Skevington SM, Langdon JE, Giddins G. Psychol Health Med. 2012;17:1-16.

COMMENTARY

Passing the "Yo' Mama" test.

Blair R. Health Manage Tech. June 2006;27:16.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

COMMENTARY

Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust.

Scholefield H. Best Pract Res Clin Obstet Gynaecol. 2007;21:593-607.

TOOLKIT

Manchester Patient Safety Framework (MaPSaF).

Manchester, UK: University of Manchester; 2006.

BOOK/REPORT

Misadventures in Health Care: Inside Stories.

Bogner MS, ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2004. ISBN: 0805833781.

STUDY

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.

Sujan MA. Reliab Eng Sys Saf. 2012;101:21-34.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

COMMENTARY

Lost in Transition

Beach C. AHRQ WebM&M [serial online]. Febuary 2006.

STUDY

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

Sujan MA, Ingram C, McConkey T, Cross S, Cooke MW. BMJ Qual Saf. 2011;20:549-556.

COMMENTARY

Implementing a systematic response to medication errors.

Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.

COMMENTARY

Measuring safety culture in healthcare: a case for accurate diagnosis.

Flin R. Safety Sci. 2007;45:653-667.

COMMENTARY

Have we gone too far in translating ideas from aviation to patient safety?

Rogers J, Gaba DM. BMJ. 2011;342:c7309-7310.

COMMENTARY

Medical error: the second victim.

McCay L, Wu AW. Br J Hosp Med. 2012;73:C146-C148.

CONGRESSIONAL TESTIMONY

Oversight hearing on recent patient safety issues.

Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).

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.

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