AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (6)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (23)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (40)

•Medical Complications (22)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (11)

•Psychological and Social Complications (5)

Origin/Sponsor
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Australia and New Zealand

Resource Types

•Book/Report (5)

•Journal Article (149)

•Legislation/Regulation (1)

•Newsletter/Journal (1)

•Special or Theme Issue (2)

Error Types

•Epidemiology of Errors and Adverse Events (82)

•Active Errors (29)

•Latent Errors (3)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (25)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (50)

•Communication Improvement (33)

•Human Factors Engineering (16)

•Teamwork (8)

•Specialization of Care (37)

•Logistical Approaches (7)

•Culture of Safety (10)

•Technologic Approaches (18)

•Education and Training (27)

Clinical Areas

•Allied Health Services (3)

•Medicine (136)

•Nursing (11)

•Pharmacy (12)

Target Audience

•Health Care Providers (92)

•Health Care Executives and Administrators (127)

•Non-Health Care Professionals (48)

•Patients (2)

Setting of Care

•Hospitals (123)

•Residential Facilities (1)

•Ambulatory Care (13)

•Patient Transport (8)

1 - 20 of 158

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STUDY

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation.

Schneider A, Calzavacca P, Jones D, Bellomo R. Resuscitation. 2011;82:410-414.

REVIEW

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.

STUDY

Problems and solutions arising during a study in visual semantics of the medical emergency team system.

Santiano N, Baramy LS, Young L, et al. Qual Health Res. 2008 ct: 18: 1336-44.

REVIEW

The effect of medical emergency teams on patient outcome: a review of the literature.

Laurens NH, Dwyer TA. Int J Nurs Pract. 2010;16:533-544.

STUDY

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

Callen J, McIntosh J, Li J. Int J Med Inform. 2010;79:58-64.

STUDY

What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.

Shearer B, Marshall S, Buist MD, et al. BMJ Qual Saf. 2012;21:569-575.

STUDY

Long-term reduction in adverse drug events: an evidence-based improvement model.

Gazarian M, Graudins LV. Pediatrics. 2012;129:e1334-e1342.

REVIEW

Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?

Massey D, Aitken LM, Chaboyer W. J Clin Nurs. 2010;19:3260-3273.

STUDY

Analysis of medical emergency team calls comparing subjective to "objective" call criteria.

Santiano N, Young L, Hillman K, et al. Resuscitation. 2008;80:44-49.

STUDY

classic

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

STUDY

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.

Mitchell IA, McKay H, Van Leuvan C, et al. Resuscitation. 2010;81:658-666.

STUDY

Documentation of clinical review and vital signs after major surgery.

McGain F, Cretikos MA, Jones D, et al. Med J Aust. 2008;189:380-383.

STUDY

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.

STUDY

Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects.

Magrabi F, Li SY, Day RO, Coiera E. J Am Med Inform Assoc. 2010;17:575-583.

REVIEW

classic

Rapid-response teams.

Jones DA, DeVita MA, Bellomo R. N Engl J Med. 2011;365:139-146.

ORGANIZATIONAL POLICY/GUIDELINES

Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement.

Peberdy MA, Cretikos M, Abella BS, et al; International Liaison Committee on Resuscitation; American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Perioperative, and Critical Care; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2007;116:2481-2500.

STUDY

Patient safety culture: factors that influence clinician involvement in patient safety behaviours.

Wakefield JG, McLaws ML, Whitby M, Patton L. Qual Saf Health Care. 2010;19:585-591.

STUDY

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

Santamaria J, Tobin A, Holmes J. Crit Care Med. 2010;38:445-450.

REVIEW

Interruptions in healthcare: theoretical views.

Grundgeiger T, Sanderson P. Int J Med Inform. 2009;78:293-307.

STUDY

Adverse event rates as measures of hospital performance.

Hauck K, Zhao X, Jackson T. Health Policy. 2012;104:146-154.

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