AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (19)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (40)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (110)

•Medical Complications (51)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (44)

•Transfusion Complications (1)

•Psychological and Social Complications (17)

Origin/Sponsor

•Africa (1)

•Asia (5)

•Australia and New Zealand (12)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (457)

•Legislation/Regulation (3)

•Newspaper/Magazine Article (5)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Tools/Toolkit (7)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (96)

•Active Errors (51)

•Latent Errors (28)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (114)

•Legal and Policy Approaches (63)

•Error Reporting and Analysis (170)

•Communication Improvement (99)

•Human Factors Engineering (46)

•Teamwork (43)

•Specialization of Care (30)

•Logistical Approaches (42)

•Culture of Safety (87)

•Technologic Approaches (90)

•Education and Training (69)

Clinical Areas

•Medicine (220)

•Nursing (22)

•Pharmacy (25)

Target Audience

•Health Care Providers (400)

•Health Care Executives and Administrators (335)

•Non-Health Care Professionals (198)

•Patients (34)

Setting of Care

•Hospitals (289)

•Residential Facilities (2)

•Ambulatory Care (32)

•Outpatient Surgery (2)

1 - 20 of 574

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REVIEW

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.

AUDIOVISUAL Search

"To Err Is Human" Report Retrospective and the Decade Ahead.

2009 NPSF Congress: Lucian Leape Institute Plenary. Boston, MA: National Patient Safety Foundation; May 21, 2009.

FACT SHEET/FAQS Search

10 Patient Safety Tips for Hospitals.

Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.

COMMENTARY Search

40 years behind the mask: safety revisited.

Pierce EC. Anesthesiology. 1996;29:965-975.

COMMENTARY Search

A 38-year-old woman with fetal loss and hysterectomy.

Sachs BP. JAMA. 2005;294:833-840.

COMMENTARY Search

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

COMMENTARY Search

A call to excellence.

Clancy CM, Scully T. Health Aff (Millwood). 2003;22:113-115.

STUDY

A classification system for incidents and accidents in the health-care system.

Runciman WB, Helps SC, Sexton EJ, Malpass A. J Qual Clin Prac. 1998;18:199-211.

ORGANIZATIONAL POLICY/GUIDELINES Search

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.

STUDY

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.

Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. 2007;82:1040-1048.

STUDY

A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.

Raschke RA, Gollihare B, Wunderlich TA, et al. [published correction appears in JAMA. 1999;281:420]. JAMA. 1998;280:1317-1320.

STUDY

A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.

Rothschild JM, Keohane CA, Cook EF, et al. Crit Care Med. 2005;33:533-540.

STUDY

A framework for engaging physicians in quality and safety.

Taitz JM, Lee TH, Sequist TD. BMJ Qual Saf. 2012;21:722-728.

COMMENTARY Search

A hospitalization from hell: a patient's perspective on quality.

Cleary PD. Ann Intern Med. 2003;138:33-39.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

STUDY

A look into the nature and causes of human errors in the intensive care unit.

Donchin Y, Gopher D, Olin M, et al. Crit Care Med. 1995;23:294-300.

COMMENTARY Search

A middle ground on public accountability.

Lee TH, Meyer GS, Brennan TA. N Engl J Med. 2004;350:2409-2412.

STUDY

A national profile of patient safety in U.S. hospitals.

Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. Health Aff (Millwood). 2003;22:154-166.

STUDY

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

Avery AJ, Rodgers S, Cantrill JA, et al. Lancet. 2012;379:1310-1319.

COMMENTARY Search

A piece of my mind. Coping with fallibility.

Levinson W, Dunn PM. JAMA. 1989;261:2252.

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