AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (60)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (166)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (193)

•Medical Complications (73)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (67)

•Transfusion Complications (3)

•Psychological and Social Complications (41)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (11)

•Central and South America (2)

•Europe (43)

•North America (838)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (39)

•Active Errors (156)

•Latent Errors (101)

•Near Miss (13)

Approach to Improving Safety

•Quality Improvement Strategies (275)

•Legal and Policy Approaches (159)

•Error Reporting and Analysis (249)

•Communication Improvement (270)

•Human Factors Engineering (122)

•Teamwork (111)

•Specialization of Care (75)

•Logistical Approaches (77)

•Culture of Safety (262)

•Technologic Approaches (169)

•Education and Training (264)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (720)

•Health Care Executives and Administrators (803)

•Non-Health Care Professionals (433)

•Patients (27)

Setting of Care

•Hospitals (588)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (67)

•Outpatient Surgery (3)

•Patient Transport (4)

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COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.

Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape L. Nat Sci Sleep. 2011;3:47-85.

COMMENTARY

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

Guralnick S, Rushton J, Bale JF Jr, Norwood V, Trimm F, Schumacher D. Pediatrics. 2010;125:786-790.

COMMENTARY

The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.

Iglehart JK. N Engl J Med. 2010;363:1589-1591.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

COMMENTARY

Sleep deprivation, physician performance, and patient safety.

Olson EJ, Drage LA, Auger RR. Chest. 2009;136:1389-1396.

COMMENTARY

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Pastores SM, O’Connor MF, Kleinpell RM, et al. Crit Care Med. 2011;39:2540-2549.

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

COMMENTARY

Perspective: ten thousand hours to patient safety, sooner or later.

Pellegrini VD Jr. Acad Med. 2012;87:164-167.

COMMENTARY

Building physician work hour regulations from first principles and best evidence.

Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

COMMENTARY

Putting the sleepy resident issue to bed: federal legislation is not the answer to excessive medical resident working hours.

Stone JD. Suffolk Univ Law Rev. 2007;40:745-767.

COMMENTARY

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 Institute of Medicine resident duty hours recommendations.

Wagner MJ, Wolf S, Promes S, et al. J Emerg Med. 2010;39:348-355.

COMMENTARY

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.

Schumacher DJ, Slovin SR, Riebschleger MP, Englander R, Hicks PJ, Carraccio C. Acad Med. 2012;87:883-888.

COMMENTARY

Professionalism in the era of duty hours: time for a shift change?

Arora VM, Farnan JM, Humphrey HJ. JAMA. 2012;308:2195-2196.

COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

COMMENTARY

Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery.

Grady MS, Batjer HH, Dacey RG. J Neurosurg. 2009;110:828-836.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

COMMENTARY

Duty hour reform in a shifting medical landscape.

Jena AB, Prasad V. J Gen Intern Med. 2013 Apr 9; [Epub ahead of print].

COMMENTARY

Excessive work hours of physicians in training in El Salvador: putting patients at risk.

Fernández Taylor KR. PLoS Med. 2007;4:e205.

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