AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (3)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (11)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (23)

•Medical Complications (4)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (4)

•Psychological and Social Complications (3)

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

Resource Types

•Book/Report (2)

•Journal Article (49)

•Meeting/Conference (1)

•Newspaper/Magazine Article (1)

•Tools/Toolkit (2)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (3)

•Active Errors (24)

•Latent Errors (15)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (19)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (11)

•Communication Improvement (20)

•Human Factors Engineering (19)

•Teamwork (7)

•Specialization of Care (3)

•Logistical Approaches (11)

•Culture of Safety (11)

•Technologic Approaches (14)

•Education and Training (16)

Clinical Areas

•Medicine (32)

•Nursing (36)

•Pharmacy (5)

Target Audience

•Health Care Providers (50)

•Health Care Executives and Administrators (31)

•Non-Health Care Professionals (18)

•Patients (1)

Setting of Care

•Hospitals (35)

•Residential Facilities (4)

•Ambulatory Care (2)

•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

Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.

Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:180-183.

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.

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.

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.

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.

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.

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.

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

COMMENTARY

Limiting nurse overtime, and promoting other good working conditions, influences patient safety.

Collins Sharp BA, Clancy CM. J Nurs Care Qual. 2008;23:97-100.

COMMENTARY

Development of a patient safety web-based education curriculum for physicians, nurses, and patients.

Hendee WR, Keating-Christensen C, Loh YH. J Patient Saf. 2005;1:90-99.

STUDY

Impact of barcode medication administration technology on how nurses spend their time providing patient care.

Poon EG, Keohane CA, Bane A, et al. J Nurs Adm. 2008;38:541-549.

COMMENTARY

The importance of simulation: preventing hand-off mistakes.

Clancy CM. AORN J. 2008;88:625-627.

STUDY

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

Schuerer DJ, Nast PA, Harris CB, et al. J Am Coll Surg. 2006;202:881-887.

MULTI-USE WEBSITE

Simulation Training for Rapid Assessment & Improved Teamwork (STRAIT) Project.

Center for Perioperative Research in Quality, Vanderbilt University.

COMMENTARY

Patient Mix-Up.

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

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