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 (29)

•Diagnostic Errors (18)

•Identification Errors (16)

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

•Fatigue and Sleep Deprivation (5)

•Medication Safety (115)

•Medical Complications (98)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (88)

•Transfusion Complications (2)

•Psychological and Social Complications (37)

Origin/Sponsor

•Africa (1)

•Asia (2)

•Australia and New Zealand (14)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (518)

•Legislation/Regulation (8)

•Meeting/Conference (16)

•Newspaper/Magazine Article (88)

•Press Release/Announcement (4)

•Special or Theme Issue (31)

•Tools/Toolkit (13)

•Web Resource (27)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (83)

•Active Errors (58)

•Latent Errors (60)

•Near Miss (11)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (15)

•Red Rules (2)

•Institutional Patient Safety Plan (10)

•Just Culture (14)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (552)

•Health Care Executives and Administrators (693)

•Non-Health Care Professionals (369)

•Patients (55)

Setting of Care

•Hospitals (468)

•Psychiatric Facilities (2)

•Residential Facilities (23)

•Ambulatory Care (53)

•Outpatient Surgery (4)

•Patient Transport (7)

1 - 20 of 817

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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].

REVIEW

Pediatric patient safety in the prehospital/emergency department setting.

Barata IA, Benjamin LS, Mace SE, Herman MI, Goldman RD. Pediatr Emerg Care. 2007;23:412-418.

BOOK/REPORT classic

Patient Safety in Emergency Medicine.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

STUDY

The Emergency Medical Services Safety Attitudes Questionnaire.

Patterson PD, Huang DT, Fairbanks RJ, Wang HE. Am J Med Qual. 2010;25:109-115.

SPECIAL OR THEME ISSUE

Safety in EMS.

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

STUDY

Pediatric patient safety in emergency departments: unit characteristics and staff perceptions.

Shaw KN, Ruddy RM, Olsen CS, et al; Pediatric Emergency Care Applied Research Network. Pediatrics. 2009;124:485-493.

BOOK/REPORT

Pediatric Patient Safety in the Emergency Department.

Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Quality initiatives: developing a radiology quality and safety program: a primer.

Johnson CD, Krecke KN, Roberts RM, Denham C. Radiographics. 2009;29:951-959.

COMMENTARY

Patient safety in women's health care: a framework for progress.

Gluck PA. Best Pract Res Clin Obstet Gynaecol. 2007;21:525-36.

COMMENTARY

To LP or not LP.

Landrigan CP. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

One intensive care nursery's experience with enhancing patient safety.

Alton M, Mericle J, Brandon D. Adv Neonatal Care. 2006;6:112-119.

STUDY

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

COMMENTARY classic

Creating an integrated patient safety team.

Gandhi TK, Graydon-Baker E, Barnes JN, et al. Jt Comm J Qual Saf. 2003;29:383-390.

ORGANIZATIONAL POLICY/GUIDELINES

Radiation risks of diagnostic imaging.

Sentinel Event Alert #47. August 24, 2011.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

BOOK/REPORT classic

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

COMMENTARY

An implementation strategy for a multicenter pediatric rapid response system in Ontario.

Lobos A, Costello J, Gilleland J, Gaiteiro R, Kotsakis A; The Ontario Pediatric Critical Care Response Team Collaborative. Jt Comm J Qual Patient Saf. 2010;36:271-280.

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.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

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