AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (173)

•Diagnostic Errors (201)

•Identification Errors (133)

•Discontinuities, Gaps, and Hand-Off Problems (601)

•Fatigue and Sleep Deprivation (114)

•Medication Safety (1203)

•Medical Complications (497)

•Nonsurgical Procedural Complications (103)

•Surgical Complications (437)

•Transfusion Complications (24)

•Psychological and Social Complications (180)

Origin/Sponsor
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United States of America

•United States Federal Government (334)

•State Governments and Agencies (49)

Resource Types

•Clinical Guideline (9)

•Journal Article (2958)

•Legislation/Regulation (66)

•Meeting/Conference (32)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (593)

•Press Release/Announcement (29)

•Special or Theme Issue (59)

•Tools/Toolkit (82)

•Web Resource (125)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (859)

•Active Errors (628)

•Latent Errors (284)

•Near Miss (76)

Approach to Improving Safety

•Quality Improvement Strategies (1051)

•Legal and Policy Approaches (468)

•Error Reporting and Analysis (1188)

•Communication Improvement (1210)

•Human Factors Engineering (525)

•Teamwork (361)

•Specialization of Care (298)

•Logistical Approaches (364)

•Culture of Safety (590)

•Technologic Approaches (755)

•Education and Training (861)

Clinical Areas

•Allied Health Services (10)

Target Audience

•Health Care Providers (3123)

•Health Care Executives and Administrators (3293)

•Non-Health Care Professionals (1576)

•Patients (435)

Setting of Care

•Hospitals (2861)

•Psychiatric Facilities (16)

•Residential Facilities (76)

•Ambulatory Care (420)

•Outpatient Surgery (50)

•Patient Transport (25)

1 - 20 of 4349

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REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

REVIEW

A systematic review of failures in handoff communication during intrahospital transfers.

Ong MS, Coiera E. Jt Comm J Qual Patient Saf. 2011;37:274-284.

COMMENTARY

Complementary telephone strategies to improve postdischarge communication.

Rennke S, Kesh S, Neeman N, Sehgal NL. Am J Med. 2012;125:28-30.

STUDY

Improving teamwork on general medical units: when teams do not work face-to-face.

McComb SA, Henneman EA, Hinchey KT, et al. Jt Comm J Qual Patient Saf. 2012;38:471-478.

STUDY

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

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

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

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

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

STUDY

Language barriers and understanding of hospital discharge instructions.

Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Med Care. 2012;50:283-289.

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.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

COMMENTARY

Handovers from the OR to the ICU.

Bonifacio AS, Segall N, Barbeito A, Taekman J, Schroeder R, Mark JB. Int Anesthesiol Clin. 2013;51:43-61.

MULTI-USE WEBSITE

Aware in Care.

Miami, FL: National Parkinson Foundation; October 2012.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

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

STUDY

Beyond communication: the role of standardized protocols in a changing health care environment.

Vardaman JM, Cornell P, Gondo MB, Amis JM, Townsend-Gervis M, Thetford C. Health Care Manage Rev. 2012;37:88-97.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

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