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 (19)

•Diagnostic Errors (11)

•Identification Errors (10)

•Discontinuities, Gaps, and Hand-Off Problems (38)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (109)

•Medical Complications (73)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (76)

•Transfusion Complications (1)

•Psychological and Social Complications (40)

Origin/Sponsor

•Africa (1)

•Asia (10)

•Australia and New Zealand (20)

•Central and South America (3)

Resource Types

•Journal Article (480)

•Legislation/Regulation (6)

•Meeting/Conference (9)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (46)

•Special or Theme Issue (23)

•Tools/Toolkit (13)

•Web Resource (11)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (63)

•Active Errors (41)

•Latent Errors (43)

•Near Miss (10)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (23)

•Red Rules (2)

•Institutional Patient Safety Plan (8)

•Just Culture (11)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (371)

•Health Care Executives and Administrators (596)

•Non-Health Care Professionals (356)

•Patients (16)

Setting of Care

•Hospitals (382)

•Psychiatric Facilities (2)

•Residential Facilities (21)

•Ambulatory Care (43)

•Outpatient Surgery (2)

•Patient Transport (7)

1 - 20 of 649

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STUDY

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.

Braithwaite J, Westbrook MT, Robinson M, Michael S, Pirone C, Robinson P. BMJ Qual Saf. 2011;20:424-431.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

REVIEW

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

STUDY

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

Forsythe L. Simul Healthc. 2009;4:143-148.

COMMENTARY

How to Identify and Manage Problem Behaviors.

Rosenstein AH, O'Daniel M. AHRQ WebM&M [serial online]. December 2009.

STUDY

Worries and concerns experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident study.

Gustafsson M, Wennerholm S, Fridlund B. Intensive Crit Care Nurs. 2010;26:138-145.

TOOLKIT

Manchester Patient Safety Framework (MaPSaF).

Manchester, UK: University of Manchester; 2006.

REVIEW

What is patient safety culture? A review of the literature.

Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. J Nurs Scholarsh. 2010;42:156-165.

SPECIAL OR THEME ISSUE

Positive Working Relationships Matter for Better Nurse and Patient Outcomes.

Spence Laschinger HK, ed. J Nurs Manag. 2010;18:875-1086.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.

Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM Jr. J Am Coll Surg. 2007;205:778-784.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

STUDY

The impact of a tele-ICU on provider attitudes about teamwork and safety climate.

Chu-Weininger MYL, Wueste L, Lucke JF, Weavind L, Mazabob J, Thomas EJ. Qual Saf Health Care. 2010;19:e39.

BOOK/REPORT

Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report.

Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; August 2011. AHRQ Publication No. 11-0071.

STUDY

Nurse decision making in the prearrest period.

Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.

STUDY

The safety culture in a children's hospital.

Grant MJC, Donaldson AE, Larsen GY. J Nurs Care Qual. 2006;21:223-229.

COMMENTARY

Passing the "Yo' Mama" test.

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

SPECIAL OR THEME ISSUE

Safety in EMS.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.

NEWSPAPER/MAGAZINE ARTICLE

The dawn of the robo-docs.

Weber DO. Hosp Health Netw. March 14, 2006.

COMMENTARY

Improving hospital performance: culture change is not the answer.

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

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