AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (122)

•Diagnostic Errors (151)

•Identification Errors (105)

•Discontinuities, Gaps, and Hand-Off Problems (310)

•Fatigue and Sleep Deprivation (71)

•Medication Safety (809)

•Medical Complications (305)

•Nonsurgical Procedural Complications (83)

•Surgical Complications (315)

•Transfusion Complications (16)

•Psychological and Social Complications (99)

Origin/Sponsor
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United States of America

•United States Federal Government (104)

•State Governments and Agencies (18)

Resource Types

•Audiovisual (41)

•Bibliography (2)

•Book/Report (160)

•Clinical Guideline (8)

•Journal Article (1859)

•Legislation/Regulation (40)

•Meeting/Conference (23)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (362)

•Press Release/Announcement (29)

•Special or Theme Issue (41)

•Tools/Toolkit (48)

•Web Resource (83)

Error Types

•Epidemiology of Errors and Adverse Events (591)

•Active Errors (598)

•Latent Errors (172)

•Near Miss (65)

Approach to Improving Safety

•Quality Improvement Strategies (634)

•Legal and Policy Approaches (317)

•Error Reporting and Analysis (767)

•Communication Improvement (706)

•Human Factors Engineering (365)

•Teamwork (204)

•Specialization of Care (197)

•Logistical Approaches (185)

•Culture of Safety (333)

•Technologic Approaches (439)

•Education and Training (496)

Clinical Areas

•Allied Health Services (9)

•Dentistry (2)

•Medicine (1863)

•Nursing (163)

•Pharmacy (297)

Target Audience

•Health Care Providers (2364)

•Health Care Executives and Administrators (2096)

•Non-Health Care Professionals (917)

•Patients (293)

Setting of Care

•Hospitals (1560)

•Psychiatric Facilities (14)

•Residential Facilities (99)

•Ambulatory Care (296)

•Outpatient Surgery (39)

•Patient Transport (26)

1 - 20 of 2746

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STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

REVIEW

Disclosure of harmful medical errors in out-of-hospital care.

Lu DW, Guenther E, Wesley AK, Gallagher TH. Ann Emerg Med. 2013;61:215-221.

STUDY

Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management.

Fairfax LM, Christmas AB, DeAugustinis M, et al. Am Surg. 2009;75:558-564.

STUDY

Inaccuracy of ECG interpretations reported to the poison center.

Prosser JM, Smith SW, Rhim ES, Olsen D, Nelson LS, Hoffman RS. Ann Emerg Med. 2011;57:122-127.

STUDY

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

STUDY

Accuracy of radiographic readings in the emergency department.

Petinaux B, Bhat R, Boniface K, Aristizabal J. Am J Emerg Med. 2011;29:18-25.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

REVIEW

Epidemiology of medication-related adverse events in nursing homes.

Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

STUDY

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

Spector WD, Mutter R, Owens P, Limcangco R. Med Care. 2012;50:863-869.

ORGANIZATIONAL POLICY/GUIDELINES

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2011;96:1312-1314.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

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