AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (14)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (28)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (38)

•Medical Complications (16)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (11)

•Transfusion Complications (2)

•Psychological and Social Complications (15)

Origin/Sponsor
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Agency for Healthcare Research and Quality (AHRQ)

Resource Types

•Audiovisual (5)

•Book/Report (13)

•Journal Article (82)

•Meeting/Conference (5)

•Newspaper/Magazine Article (1)

•Tools/Toolkit (6)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (8)

•Active Errors (46)

•Latent Errors (30)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (45)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (32)

•Communication Improvement (44)

•Human Factors Engineering (39)

•Teamwork (15)

•Specialization of Care (7)

•Logistical Approaches (25)

•Culture of Safety (29)

•Technologic Approaches (34)

•Education and Training (52)

Clinical Areas

•Medicine (68)

•Nursing (37)

•Pharmacy (8)

Target Audience

•Health Care Providers (96)

•Health Care Executives and Administrators (69)

•Non-Health Care Professionals (52)

•Patients (4)

Setting of Care

•Hospitals (70)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (13)

•Outpatient Surgery (1)

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STUDY

Understanding the cognitive work of nursing in the acute care environment.

Potter P, Wolf L, Boxerman S, et al. J Nurs Adm. 2005;35:327-335.

COMMENTARY

Working conditions that support patient safety.

Hughes RG, Clancy CM. J Nurs Care Qual. 2005;20:289-292.

STUDY

Quantifying nursing workflow in medication administration.

Keohane CA, Bane AD, Featherstone E, et al. J Nurs Admin. 2008;38:19-26.

COMMENTARY

Patient safety in nursing practice.

Clancy CM, Farquhar MB, Collins Sharp BA. J Nurs Care Qual. 2005;20:193-197.

STUDY

classic

The working hours of hospital staff nurses and patient safety.

Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. Health Aff (Millwood). 2004;23:202-212.

COMMENTARY

Patient safety in nursing practice.

Farquhar M, Collins Sharp BA, Clancy CM. AORN J. 2007;86:455-457.

COMMENTARY

Nurses' role in patient safety.

Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:1-4.

BOOK/REPORT

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.

COMMENTARY

Reducing pediatric medication errors: children are especially at risk for medication errors.

Hughes RG, Edgerton EA. Am J Nurs. May 2005;105:79-84.

COMMENTARY

Patient Mix-Up.

Shojania KG. AHRQ WebM&M [serial online]. February 2003.

BOOK/REPORT classic

classic

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.

MEETING/CONFERENCE PROCEEDINGS

The State of the Science on Safe Medication Administration.

Am J Nurs. March 2005;105(suppl 3):1-47.

STUDY

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement.

Zrelak PA, Utter GH, Sadeghi B, Cuny J, Baron R, Romano PS. J Nurs Care Qual. 2012;27:99-108.

NEWSPAPER/MAGAZINE ARTICLE

Health IT implementation stories: HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study.

AHRQ National Resource Center for Health Information Technology.

COMMENTARY

Do Me a Favor.

Williamson A. AHRQ WebM&M [serial online]. May 2004.

AUDIOVISUAL

Tools, Methods, and Techniques for Improving Patient Safety: Patient Safety Improvement Corps Training DVD.

Rockville, MD: Agency for Healthcare Research and Quality; 2007.

COMMENTARY

Waiting Too Long.

Rosen MA. AHRQ WebM&M [serial online]. November 2003.

GRANT ANNOUNCEMENT

AHRQ Health Services Research Projects (R01).

US Department of Health and Human Services. Program Announcement No. PA-09-070.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

STUDY

Working conditions in primary care: physician reactions and care quality.

Linzer M, Manwell LB, Williams ES, et al; MEMO Investigators. Ann Intern Med. 2009;151:28-36.

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