AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (4)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (26)

•Medication Safety (97)

•Medical Complications (18)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (9)

•Psychological and Social Complications (3)

Origin/Sponsor

•Australia and New Zealand (2)

•North America (154)

Resource Types

•Audiovisual (12)

•Book/Report (16)

•Journal Article (80)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (27)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Tools/Toolkit (20)

•Web Resource (15)

Error Types

•Epidemiology of Errors and Adverse Events (13)

•Active Errors (22)

•Latent Errors (11)

•Near Miss (1)

Approach to Improving Safety
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Patient Education

Clinical Areas

•Medicine (105)

•Pharmacy (49)

Target Audience

•Health Care Providers (119)

•Health Care Executives and Administrators (81)

•Non-Health Care Professionals (39)

•Patients (80)

Setting of Care

•Hospitals (79)

•Residential Facilities (1)

•Ambulatory Care (44)

•Outpatient Surgery (1)

1 - 20 of 176

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STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

BOOK/REPORT

Patient-Centered Care Improvement Guide.

Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

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

COMMENTARY

Developing a medication patient safety program, part 2: process and implementation.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:249–254.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

BOOK/REPORT

Managing Patients' Medicines after Discharge from Hospital.

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

AUDIOVISUAL PRESENTATION

Drug shortages and how they affect your healthcare.

Faye J. NBC-17 News. November 10, 2011.

AUDIOVISUAL

How to Make Your Hospital Stay Safer and Cheaper: A Checklist.

Kane J. PBS NewsHour. October 23, 2012.

NEWSPAPER/MAGAZINE ARTICLE

10 things your hospital won't tell you.

Kapadia R. Smart Money. October 2006;15:112-114.

BOOK/REPORT

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.

Oakbrook Terrace, IL: The Joint Commission; 2010.

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.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

COMMENTARY

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

Clancy CM. Am J Med Qual. 2009;24:344-346.

STUDY

Hospitalized patients' understanding of their plan of care.

O'Leary KJ, Kulkarni N, Landler MP, et al. Mayo Clin Proc. 2010;85:47-52.

STUDY

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2010;67:542-558.

STUDY

Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital.

Karapinar-Çarkit F, Borgsteede SD, Zoer J, Smit HJ, Egberts ACG, van den Bemt PMLA. Ann Pharmacother. 2009;43:1001-1010.

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