AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (175)

•Diagnostic Errors (169)

•Identification Errors (111)

•Discontinuities, Gaps, and Hand-Off Problems (402)

•Fatigue and Sleep Deprivation (95)

•Medication Safety (1060)

•Medical Complications (505)

•Nonsurgical Procedural Complications (79)

•Surgical Complications (392)

•Transfusion Complications (19)

•Psychological and Social Complications (118)

Origin/Sponsor
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United States of America

•United States Federal Government (264)

•State Governments and Agencies (43)

Resource Types

•Clinical Guideline (11)

•Journal Article (2540)

•Legislation/Regulation (65)

•Meeting/Conference (37)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (443)

•Press Release/Announcement (38)

•Special or Theme Issue (55)

•Tools/Toolkit (62)

•Web Resource (125)

•Grant (12)

Error Types

•Epidemiology of Errors and Adverse Events (1050)

•Active Errors (472)

•Latent Errors (204)

•Near Miss (66)

Approach to Improving Safety

•Quality Improvement Strategies (1009)

•Legal and Policy Approaches (431)

•Error Reporting and Analysis (1053)

•Communication Improvement (834)

•Human Factors Engineering (428)

•Teamwork (272)

•Specialization of Care (279)

•Logistical Approaches (272)

•Culture of Safety (543)

•Technologic Approaches (637)

•Education and Training (670)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2821)

•Health Care Executives and Administrators (2957)

•Non-Health Care Professionals (1387)

•Patients (308)

Setting of Care

•Hospitals (2243)

•Psychiatric Facilities (15)

•Residential Facilities (73)

•Ambulatory Care (350)

•Outpatient Surgery (48)

•Patient Transport (24)

1 - 20 of 3739

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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.

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

Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.

Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

STUDY

Multiprofessional survey of protocol use in the intensive care unit.

LeBlanc JM, Kane-Gill SL, Pohlman AS, Herr DL. J Crit Care. 2012;27:738.e9-738.e17.

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.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

COMMENTARY

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

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

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

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

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.

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

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

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

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.

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

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

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.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

ORGANIZATIONAL POLICY/GUIDELINES classic

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.

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