AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (37)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (69)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (73)

•Medical Complications (42)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (25)

•Transfusion Complications (3)

•Psychological and Social Complications (12)

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

Resource Types

•Audiovisual (11)

•Book/Report (45)

•Clinical Guideline (1)

•Journal Article (159)

•Legislation/Regulation (1)

•Meeting/Conference (9)

•Newspaper/Magazine Article (5)

•Press Release/Announcement (8)

•Special or Theme Issue (6)

•Tools/Toolkit (29)

•Web Resource (21)

Error Types

•Epidemiology of Errors and Adverse Events (41)

•Active Errors (74)

•Latent Errors (51)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (112)

•Legal and Policy Approaches (40)

•Error Reporting and Analysis (93)

•Communication Improvement (98)

•Human Factors Engineering (42)

•Teamwork (28)

•Specialization of Care (19)

•Logistical Approaches (28)

•Culture of Safety (62)

•Technologic Approaches (74)

•Education and Training (68)

Clinical Areas

•Allied Health Services (1)

•Medicine (182)

•Nursing (22)

•Pharmacy (21)

Target Audience

•Health Care Providers (210)

•Health Care Executives and Administrators (197)

•Non-Health Care Professionals (134)

•Patients (23)

Setting of Care

•Hospitals (189)

•Psychiatric Facilities (2)

•Residential Facilities (8)

•Ambulatory Care (47)

•Outpatient Surgery (4)

1 - 20 of 305

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STUDY

Health information technology and its effects on hospital costs, outcomes, and patient safety.

Encinosa WE, Bae J. Inquiry. Winter 2011/2012;48:288-303.

MULTI-USE WEBSITE

Project Red (Re-Engineered Discharge).

Boston, MA: Boston University Medical Center.

COMMENTARY

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

Clancy CM. Am J Med Qual. 2009;24:344-346.

STUDY

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

BOOK/REPORT

Eliminating CLABSI: A National Patient Safety Imperative.

Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.

TOOLKIT

Re-Engineered Discharge (RED) Toolkit.

Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

REVIEW

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.

MULTI-USE WEBSITE

Impact Case Studies and Knowledge Transfer Case Studies: Patient Safety.

Agency for Healthcare Research and Quality; November 2011.

REVIEW

Rapid response systems as a patient safety strategy: a systematic review.

Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Ann Intern Med. 2013;158(5 Part 2):417-425.

MULTI-USE WEBSITE

Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO).

Agency for Healthcare Quality and Research.

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

FACT SHEET/FAQS

Bar-Coded Medication Administration (BCMA).

Decisionmaker Brief. AHRQ Publication No: 08-0085, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.

COMMENTARY

CMS's hospital-acquired condition lists link hospital payment, patient safety.

Clancy CM. Am J Med Qual. 2009;24:166-168.

COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

BOOK/REPORT

Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.

Sorra J, Famloaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0030.

REVIEW

Nurse–patient ratios as a patient safety strategy: a systematic review.

Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):404-409.

REVIEW

In-facility delirium programs as a patient safety strategy: a systematic review.

Reston JT, Schoelles KM. Ann Intern Med. 2013;158(5 Pt 2):375-380.

COMMENTARY

The top patient safety strategies that can be encouraged for adoption now.

Shekelle PG, Pronovost PJ, Wachter RM, et al. Ann Intern Med. 2013;158(5 Pt 2):365-368.

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