AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (125)

•Diagnostic Errors (109)

•Identification Errors (79)

•Discontinuities, Gaps, and Hand-Off Problems (312)

•Fatigue and Sleep Deprivation (93)

•Medication Safety (768)

•Medical Complications (331)

•Nonsurgical Procedural Complications (65)

•Surgical Complications (315)

•Transfusion Complications (13)

•Psychological and Social Complications (120)

Origin/Sponsor
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United States of America

•United States Federal Government (154)

•State Governments and Agencies (35)

Resource Types

•Audiovisual (34)

•Bibliography (3)

•Book/Report (232)

•Clinical Guideline (6)

•Journal Article (2110)

•Legislation/Regulation (48)

•Meeting/Conference (40)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (369)

•Press Release/Announcement (26)

•Special or Theme Issue (58)

•Tools/Toolkit (52)

•Web Resource (120)

Error Types

•Epidemiology of Errors and Adverse Events (564)

•Active Errors (376)

•Latent Errors (164)

•Near Miss (48)

Approach to Improving Safety

•Quality Improvement Strategies (786)

•Legal and Policy Approaches (366)

•Error Reporting and Analysis (822)

•Communication Improvement (751)

•Human Factors Engineering (337)

•Teamwork (272)

•Specialization of Care (207)

•Logistical Approaches (219)

•Culture of Safety (524)

•Technologic Approaches (504)

•Education and Training (769)

Clinical Areas

•Allied Health Services (10)

•Dentistry (3)

•Medicine (1923)

•Nursing (144)

•Pharmacy (274)

Target Audience

•Health Care Providers (2460)

•Health Care Executives and Administrators (2603)

•Non-Health Care Professionals (1441)

•Patients (238)

Setting of Care

•Hospitals (1787)

•Psychiatric Facilities (11)

•Residential Facilities (57)

•Ambulatory Care (274)

•Outpatient Surgery (36)

•Patient Transport (19)

1 - 20 of 3154

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REVIEW

There's a science for that: team development interventions in organizations.

Shuffler ML, DiazGranados D, Salas E. Curr Dir Psychol Sci. 2011;20:365-372.

STUDY

Association of resident fatigue and distress with perceived medical errors.

West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. JAMA. 2009;302:1294-1300.

STUDY

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.

Drolet BC, Spalluto LB, Fischer SA. N Engl J Med. 2010;363:e34.

SPECIAL OR THEME ISSUE

Quality and Safety in Medicine.

Nash DB, Goldfarb NI, Patow C, eds. Acad Med. 2009;84:1641-1846.

UPCOMING MEETING/CONFERENCE

Project BOOST: improving the care of patients as they transition from hospital to home.

National Patient Safety Foundation. July 17, 2013; 2:00–3:00 PM (Eastern).

TEXAS MEETING/CONFERENCE

TeamStepps National Conference.

Agency for Healthcare Research and Quality. June 12–13, 2013; The Fairmont Dallas, Dallas, TX.

STUDY

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment.

Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-249.

STUDY

A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.

Aboumatar HJ, Blackledge CG Jr, Dickson C, Heitmiller E, Freischlag J, Pronovost PJ. Am J Med Qual. 2007;22:232-238.

STUDY

Resident fatigue: is there a patient safety issue?

Mitchell CD, Mooty CR, Dunn EL, Ramberger KC, Mangram AJ. Am J Surg. 2009;198:811-816.

NEWSPAPER/MAGAZINE ARTICLE

That’s the way we do things around here!

ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.

REVIEW

Teamwork in obstetric critical care.

Guise JM, Segel S. Best Pract Res Clin Obstet Gynaecol. 2008;22:937-951.

STUDY

Health literacy and communication quality in health care organizations.

Wynia MK, Osborn CY. J Health Commun. 2010;15(suppl 2):102-115.

COMMENTARY

Frontline hospital workers and the worker safety/patient safety nexus.

Sokas R, Braun B, Chenven L, et al. Jt Comm J Qual Patient Saf. 2013;39:185-192.

COMMENTARY

The incorporation of patient safety into board certification examinations.

Kachalia A, Johnson JK, Miller S, Brennan T. Acad Med. 2006;81:317-325.

NEWSPAPER/MAGAZINE ARTICLE

Medical simulation gets real.

Voelker R. JAMA. 2009;302:2190-2192.

COMMENTARY

HRET Patient Safety Leadership Fellowship: The role of "community" in patient safety.

Leonhardt KK. Am J Med Qual. 2010;25:192-196.

COMMENTARY

The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.

Iglehart JK. N Engl J Med. 2010;363:1589-1591.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.

Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.

BOOK/REPORT classic

classic

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.

Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.

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