AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (74)

•Diagnostic Errors (39)

•Identification Errors (43)

•Discontinuities, Gaps, and Hand-Off Problems (165)

•Fatigue and Sleep Deprivation (56)

•Medication Safety (407)

•Medical Complications (204)

•Nonsurgical Procedural Complications (29)

•Surgical Complications (183)

•Transfusion Complications (8)

•Psychological and Social Complications (124)

Origin/Sponsor
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United States of America

•United States Federal Government (79)

•State Governments and Agencies (11)

Resource Types

•Clinical Guideline (1)

•Journal Article (1312)

•Legislation/Regulation (29)

•Meeting/Conference (29)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (301)

•Press Release/Announcement (9)

•Special or Theme Issue (48)

•Tools/Toolkit (33)

•Web Resource (58)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (253)

•Active Errors (140)

•Latent Errors (103)

•Near Miss (25)

Approach to Improving Safety

•Quality Improvement Strategies (646)

•Legal and Policy Approaches (315)

•Error Reporting and Analysis (586)

•Communication Improvement (464)

•Human Factors Engineering (205)

•Teamwork (257)

•Specialization of Care (139)

•Logistical Approaches (141)

•Culture of Safety (729)

•Technologic Approaches (303)

•Education and Training (416)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (1266)

•Health Care Executives and Administrators (1904)

•Non-Health Care Professionals (1053)

•Patients (165)

Setting of Care

•Hospitals (1221)

•Psychiatric Facilities (7)

•Residential Facilities (42)

•Ambulatory Care (123)

•Outpatient Surgery (16)

•Patient Transport (8)

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COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

STUDY

Measuring and comparing safety climate in intensive care units.

France DJ, Greevy RA Jr, Liu X, et al. Med Care. 2010;48:279-284.

STUDY

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units.

Vogus TJ, Sutcliffe KM. Med Care. 2007;45:46-54.

STUDY

Organizational factors associated with high performance in quality and safety in academic medical centers.

Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Acad Med. 2007;82:1178-1186.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

COMMENTARY

Integrating CUSP and TRIP to improve patient safety.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.

STUDY

Struggling to invent high-reliability organizations in health care settings: insights from the field.

Dixon NM, Shofer M. Health Serv Res. 2006;41(4 Pt 2):1618-1632.June 6, 2006 E-pub.

STUDY

AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.

Blegen MA, Gearhart S, O'Brien R, Sehgal NL, Alldredge BK. J Patient Saf. 2009;5:139-144.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

STUDY

Organizational climate determinants of resident safety culture in nursing homes.

Arnetz JE, Zhdanova LS, Elsouhag D, Lichtenberg P, Luborsky MR, Arnetz BB. Gerontologist. 2011;51:739-749.

STUDY

Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.

Clarke S. J Occup Organ Psychol. 2013;86:22-49.

COMMENTARY

Ambiguity and workarounds as contributors to medical error.

Spear SJ, Schmidhofer M. Ann Intern Med. 2005;142:627-630.

BOOK/REPORT

Second Victim: Error, Guilt, Trauma, and Resilience.

Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.

COMMENTARY

Facing ambiguous threats.

Roberto MA, Bohmer RM, Edmondson AC. Harv Bus Rev. 2006;84:106-113, 157.

STUDY

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Sinkowitz-Cochran RL, Garcia-Williams A, Hackbarth AD, et al. Infect Control Hosp Epidemiol. 2012;33:135-143.

BOOK/REPORT classic

Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report.

Rockville, MD: Agency for Healthcare Research and Quality; April 2007. AHRQ Publication No. 07-0025.

COMMENTARY

Improving patient safety: patient-focused, high-reliability team training.

McKeon LM, Cunningham PD, Detty Oswaks JS. J Nurs Care Qual. 2009;24:76-82.

NEWSPAPER/MAGAZINE ARTICLE

Five ways to think about patient safety.

Krause TR, Hindley JH. Trustee. November 2008;61:24-36.

BOOK/REPORT

Improving the Reliability of Health Care.

Nolan T, Resar R, Haraden C, Griffin FA. Boston, MA: Institute for Healthcare Improvement; 2004.

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