AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (11)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (14)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (12)

•Medical Complications (15)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (19)

•Transfusion Complications (1)

•Psychological and Social Complications (3)

Origin/Sponsor
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Department of Veterans Affairs (VA)

Resource Types

•Book/Report (4)

•Journal Article (80)

•Legislation/Regulation (3)

•Newspaper/Magazine Article (1)

•Press Release/Announcement (2)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (23)

•Active Errors (11)

•Latent Errors (6)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (24)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (30)

•Communication Improvement (23)

•Human Factors Engineering (17)

•Teamwork (12)

•Specialization of Care (2)

•Logistical Approaches (11)

•Culture of Safety (17)

•Technologic Approaches (23)

•Education and Training (26)

Clinical Areas

•Medicine (68)

•Pharmacy (5)

Target Audience

•Health Care Providers (77)

•Health Care Executives and Administrators (80)

•Non-Health Care Professionals (45)

Setting of Care

•Hospitals (63)

•Psychiatric Facilities (1)

•Ambulatory Care (9)

•Outpatient Surgery (1)

1 - 20 of 95

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STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

STUDY

Sharing lessons learned to prevent incorrect surgery.

Neily J, Mills PD, Paull DE, et al. Am Surg. 2012;78:1276-1280.

STUDY

The effect of facility complexity on perceptions of safety climate in the operating room: size matters.

Carney BT, West P, Neily J, Mills PD, Bagian JP. Am J Med Qual. 2010;25:457-461.

STUDY

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Am J Surg. 2009;198:675-678.

STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

STUDY

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Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

STUDY

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Video capture of clinical care to enhance patient safety.

Weinger MB, Gonzales DC, Slagle J, Syeed M. Qual Saf Health Care. 2004;13:136-144.

STUDY

Association between implementation of a medical team training program and surgical morbidity.

Young-Xu Y, Neily J, Mills PD, et al. Arch Surg. 2011;146:1368-1373.

STUDY

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

Watts BV, Percarpio K, West P, Mills PD. J Patient Saf. 2010;6:206-209.

STUDY

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Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Teamwork and communication in surgical teams: implications for patient safety.

Mills P, Neily J, Dunn E. J Am Coll Surg. 2008;206:107-112.

STUDY

Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program.

Carney BT, Mills PD, Bagian JP, Weeks WB. Qual Saf Health Care. 2010;19:128-131.

STUDY

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S. Soc Sci Med. 2010;71:1692-1701.

COMMENTARY

Patient safety: lessons learned.

Bagian JP. Pediatr Radiol. 2006;36:287-290.

STUDY

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. Jt Comm J Qual Patient Saf. 2009;35:239-246.

STUDY

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.

Singh H, Wilson L, Petersen LA, et al. BMC Med Inform Decis Mak. 2009;9:49.

COMMENTARY

Residency training at a crossroads: duty-hour standards 2010.

Volpp KG, Friedman W, Romano PS, Rosen A, Silber JH. Ann Intern Med. 2010;153:826-828.

ORGANIZATIONAL POLICY/GUIDELINES

VHA National Patient Safety Improvement Handbook.

Washington, DC: Veterans Health Administration; March 4, 2011.

CONGRESSIONAL TESTIMONY

Oversight hearing on recent patient safety issues.

Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).

PRESS RELEASE/ANNOUNCEMENT

VA Interprofessional Fellowship Program in Patient Safety.

United States Department of Veterans Affairs.

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