AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (60)

•Diagnostic Errors (55)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (151)

•Fatigue and Sleep Deprivation (62)

•Medication Safety (291)

•Medical Complications (123)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (137)

•Transfusion Complications (5)

•Psychological and Social Complications (61)

Origin/Sponsor

•Australia and New Zealand (33)

•Central and South America (4)

•Europe (132)

•North America (955)

Resource Types

•Audiovisual (20)

•Book/Report (70)

•Clinical Guideline (1)

•Journal Article (800)

•Legislation/Regulation (10)

•Meeting/Conference (26)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (107)

•Press Release/Announcement (13)

•Special or Theme Issue (26)

•Tools/Toolkit (26)

•Web Resource (63)

Error Types

•Epidemiology of Errors and Adverse Events (153)

•Active Errors (193)

•Latent Errors (74)

•Near Miss (20)

Approach to Improving Safety
< All

Education and Training

•Students (51)

•Residents and Fellows (215)

•Continuing Education (49)

•Online Education (42)

•Simulators (117)

•Teamwork Training (136)

•Patient Education (134)

Clinical Areas

•Allied Health Services (6)

•Complementary and Alternative Medicine (1)

•Dentistry (2)

•Medicine (765)

•Nursing (118)

•Pharmacy (116)

Target Audience

•Health Care Providers (856)

•Health Care Executives and Administrators (837)

•Non-Health Care Professionals (603)

•Patients (101)

Setting of Care

•Hospitals (740)

•Psychiatric Facilities (2)

•Residential Facilities (17)

•Ambulatory Care (92)

•Outpatient Surgery (6)

•Patient Transport (8)

1 - 20 of 1174

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ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.

BOOK/REPORT

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

MULTI-USE WEBSITE

BOOSTing Care Transitions Resource Room.

Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2010;15:1-4.

STUDY

Reduction in pediatric identification band errors: a quality collaborative.

Phillips SC, Saysana M, Worley S, Hain PD. Pediatrics. 2012;129:e1587-e1593.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

COMMENTARY

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

REVIEW

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

Goeschel CA, Wachter RM, Pronovost PJ. Chest. 2010;138:171-178.

BOOK/REPORT

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

BOOK/REPORT

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Health Research and Educational Trust; January 25, 2010.

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