AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (146)

•Diagnostic Errors (123)

•Identification Errors (95)

•Discontinuities, Gaps, and Hand-Off Problems (221)

•Fatigue and Sleep Deprivation (49)

•Medication Safety (686)

•Medical Complications (416)

•Nonsurgical Procedural Complications (40)

•Surgical Complications (320)

•Transfusion Complications (15)

•Psychological and Social Complications (60)

Origin/Sponsor
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United States of America

•United States Federal Government (84)

•State Governments and Agencies (11)

Resource Types

•Audiovisual (72)

•Award (11)

•Book/Report (97)

•Clinical Guideline (4)

•Journal Article (1398)

•Legislation/Regulation (13)

•Meeting/Conference (4)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (424)

•Press Release/Announcement (12)

•Special or Theme Issue (13)

•Tools/Toolkit (37)

•Web Resource (67)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (994)

•Active Errors (346)

•Latent Errors (93)

•Near Miss (48)

Approach to Improving Safety

•Quality Improvement Strategies (453)

•Legal and Policy Approaches (289)

•Error Reporting and Analysis (791)

•Communication Improvement (448)

•Human Factors Engineering (309)

•Teamwork (117)

•Specialization of Care (178)

•Logistical Approaches (157)

•Culture of Safety (223)

•Technologic Approaches (340)

•Education and Training (346)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1377)

•Health Care Executives and Administrators (1402)

•Non-Health Care Professionals (622)

•Patients (602)

Setting of Care

•Hospitals (1451)

•Psychiatric Facilities (6)

•Residential Facilities (44)

•Ambulatory Care (212)

•Outpatient Surgery (32)

•Patient Transport (18)

1 - 20 of 2159

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STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

NEWSPAPER/MAGAZINE ARTICLE

Preventing infections: how Portland hospitals compare.

Rojas-Burke J. The Oregonian. May 8, 2010.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.

PRESS RELEASE/ANNOUNCEMENT classic

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

NEWSPAPER/MAGAZINE ARTICLE

Top of the list: Researcher fights epidemic of medical errors with checklist.

MacMillan C. Republican-American. March 29, 2009;local:1A.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

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.

STUDY

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

STUDY

Intensive care units, communication between nurses and physicians, and patients' outcomes.

Manojlovich M, Antonakos CL, Ronis DL. Am J Crit Care. 2009;18:21-30.

COMMENTARY

Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.

Savel RH, Goldstein EB, Gropper MA. Crit Care Med. 2009;37:725-728.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

Needham DM, Sinopoli DJ, Thompson DA, et al. Crit Care Med. 2005;33:1701-1707.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

Waters HR, Korn R Jr, Colantuoni E, et al. Am J Med Qual. 2011;26:333-339.

STUDY

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

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